


Case Consultation: Severus S

by LadyHeliotrope



Category: Harry Potter - J. K. Rowling
Genre: Alcohol Abuse/Alcoholism, Angst with a Happy Ending, Armchair Therapy, Black Character(s), CPTSD, Childhood Trauma, Coming Out, Complicated Relationships, Dark James Potter, Depression, Dissociation, Drinking, Emotional/Psychological Abuse, F/F, Gender Confusion, Gender Dysphoria, Gender Identity, Gender Issues, Healing, James Potter Bashing, James Potter Being an Asshole, M/M, Medication side effects, Mental Anguish, Mental Breakdown, Mental Health Issues, Mental Instability, Minor Lucius Malfoy/Severus Snape, Multi, Not Canon Compliant, Original Character(s), Other, Post-Canon, Post-Traumatic Stress Disorder - PTSD, Psychological Trauma, Psychotropic medication, Realistic mental health issues, Severus Snape Has PTSD, Severus Snape Has a Heart, Severus Snape Lives, Severus Snape-centric, Sexual Abuse, Suicidal Thoughts, Therapy, Trans Character, Trans Female Character, Trans Severus Snape, Trauma, Weight Gain, Weight Issues, coming out as trans, complex PTSD, gender questioning, noblesse oblige, none of the trauma happens on-screen, psychological healing, sexual activity with minors, sexual quid pro quo
Language: English
Status: In-Progress
Published: 2020-05-13
Updated: 2021-02-25
Packaged: 2021-03-02 22:41:51
Rating: Mature
Warnings: Rape/Non-Con, Underage
Chapters: 23
Words: 24,960
Publisher: archiveofourown.org
Story URL: https://archiveofourown.org/works/24114451
Author URL: https://archiveofourown.org/users/LadyHeliotrope/pseuds/LadyHeliotrope
Summary: True to his Machiavellian form, Dumbledore had insight into Snape's tenuous grip on survival. As a result, he privately set up a magical mechanism to transport Snape to get a fresh start in a new country.  So, instead of expiring in the Shrieking Shack, after losing consciousness, Snape woke up at an Aerosmith concert in Boston. In emotional freefall, Snape's circumstances conspire to connect to mandated therapy treatment. This is the story of that treatment.Selected progress notes from Snape's therapist after the end of the wizarding war. Co-Starring Leticia Rosenberg LICSW of Boston Institute for Family Therapeutics, with cameos from Frasier Crane because why not XD
Comments: 116
Kudos: 132
Collections: Hearts and Cauldrons Discord Members, Severus Snape Lives!, Transgender Severus Snape  (FTM MTF Genderfluid  Nonbinary Intersex... and more)





	1. Psychosocial Assessment / Intake

**Author's Note:**

> hi, i'm a real life therapist in the united states, and this is a fic that accurately reflects the therapeutic process from a clinician's perspective. this is in some ways the laziest fic I've ever written because i have a form set up for writing notes and I just use that form for writing this fic ;) I even leave all my typos because I don't GAF when i'm writing actual patient notes about typos, no clinician (at least with my caseload of 50+/- patients) has time for that!!!! 
> 
> notes: in addition to being a real life therapist, I am a peer with severe and persistent mental illness. I'm neuroatypical, nonbinary, queer, and I gots the traumaz. thank you for reading this fic. if you like this story please consider checking out my other work, which has similar themes and feels and is in a more standard prose format.

Leticia Rosenberg, LICSW; LADC

Boston Institute for Family Therapeutics, LLC

1282 Carriage House Place

Somerville, MA  02143   
  


**Psychosocial Assessment**

**Patient Name: Severus S.**

**Patient Gender:** Patient presents as male; patient just scoffed when asked gender.

|  |  |   
---|---|---|---  
  
**Date of Birth: 1/9/1960**

|  | 

**Age: 38**

|   
|  | 

**Insurance: MA Medicaid**

|   
  
**Current Residence: Knight's Plaza Men's Shelter**

|  | 

**Date of Assessment: 5/28/1998**

|   
  
**Billing Address: Knight's Plaza Men's Shelter**

**Source(s) of Financial Support:**

| 

None. Patient formerly employed as schoolteacher up to approximately May 1st. No savings.  
  
---|---  
  
**Medical Treatment Provider(s):**

| 

None  
  
**Patient Phone Number:**

| 

none  
  
**Patient Emergency Contact Person:**

| 

None  
  
| 

000000000  
  
**Source of Referral:**

| 

Knight’z Plaza Men’s Shelter   
Case Manager Betsy Loran  
  
**DESCRIPTION OF THE PATIENT:**  
  
---  
  
Patient is an 38 year-old male-presenting individual, born in Cokeworth UNITED KINGDOM. Patient has lived most of their life in Hogsmeade Scotland, U.K. . Patient ethnicity is White, Not Hispanic. Patient is Undocumented; U.K. Citizen. Patient is fluent and literate in English, "I studied Latin and Greek in school." Patient identifies the following reasons for seeking treatment: "It's required."  
  


**Physical**

Patient presented for the interview in the following state of hygiene and dress: overdressed for season, general self neglect, heavy wool coat, faded gray jeans, stained/worn "Aerosmith" t-shirt. Patient physical abnormalities include the following: significant tattoos, large nose, tattoo of snake on left forearm. Patient appeared older than stated age. Patient height and build presented as follows: taller than average, slight of build, under-nourished. Patient presented with the following posture: slumped, hunched, drooped posture. Patient presented with the following eye contact: avoidant, unsettled. Patient presented with the following facial expression: furrowed brows, downward corners of mouth. Patient presented with the following physical behaviors: ambulatory, no unusual movements or abnormal motor activity.   
  


**Mental Status Exam**

Patient’s alertness presented as within normal limits, oriented to time, place, person, self, and situation. The patient’s attitude towards the interviewer was withdrawn, uninterested, indifferent, despairing, pessimistic, evasive, guarded. Patient’s speech during the interview presented as follows: coherence: normal, intelligibility: normal, adequate relevance, quality: speaking only on question, rate: slow speech, quality: hesitant, quantity: taciturn. The patient’s affect presented as follows: mood congruent, dysphoric type (depressed, irritable, angry), restricted (less range/intensity), appropriate to situation. Patient’s thought process presented as follows: associations were clear and went logically from one idea to the next without flight of ideas, productivity: only when questioned, thought content: overvalued ideas (less fixed than delusions, some basis in reality), thought content: obsessions (preoccupation with thought, acknowledged to be irrational), thought content: plans, intentions, or recurrent ideas about suicide or homicide. Patient’s mood presented as irritable, depressed, dysphoric, anhedonic, apathetic. Patient presented with the following perceptual disturbances: no abnormal sensory perceptions. The patient presented with the following insight into their illness: intellectual insight: admission of illness and recognition that symptoms or failure in social adjustment are due to irrational feelings or disturbances, without applying that knowledge to future experiences. Patient judgment presented as follows: adequate. Patient memory/concentration seemed within normal limits; average attention span, recent memory, working memory, remote memory, and intelligence, high level of intelligence.   
  


The interview took approximately 60 minutes.  
  
**FINANCIAL HISTORY AND STATUS:**  
  
---  
  
Patient’s current source of income is none. Patient formerly employed as schoolteacher up to approximately May 1st. No savings. in the amount of approximately 0. Patient has the following medical insurance: MA Medicaid. Patient has other assets: 0. Patient has 0 dependents that they are supporting on their income. Patient did not report any unusual expenses. Patient identifies the following unmet financial needs at this time: Patient refused to answer questions regarding this topic.  
  
**HOUSING HISTORY**  
  
---  
  
Patient reports housing status is: shelter. Patient currently lives in shelter dormitory. Patient identifies the following unmet housing needs at this time: working with housing specialist at shelter.  
  
**FAMILY HISTORY:**  
  
---  
  
Patient reports that they were born in Cokeworth, UNITED KINGDOM. Patient has lived most of their life in Hogsmeade Scotland, U.K. . Patient’s parental figure(s) performed the following employment during their childhood: father worked as stage-hand in vaudeville playhouse; mother was a singer at same.. Growing up, patient had involvement from mother, father. Patient lived at home until they were about 38 years old. Patient reports having had a negative childhood; Patient refused to give details. Patient’s parental figures treated the patient in a negative manner growing up. Patient’s parents currently are: mother deceased, father deceased. Patient describes their past/current relationship(s) with their parent(s) as follows: Patient asked "why do you even care? They're long dead anyway.". 

  


Patient was the only child in their family of origin. Patient had 0 siblings growing up. Patient describes their past/current relationship(s) with their siblings as follows: only. Patient’s current marital/relationship status is single. Patient describes their relationship with their significant other as follows: n/a. Patient reports having 0 children. Patient describes their relationship(s) with their child(ren) as follows: n/a.   
  
  
  
Patient identifies the following unmet family needs at this time: Patient denies any current unmet family-related needs.

**EDUCATION:**  
  
---  
  
Patient reports that they completed up to grade master's degree . Patient holds the following credentials: master's degree in chemistry. Patient desire to return to school: no. Patient identifies the following unmet education needs at this time: Patient denies any current unmet education-related needs.   
  
**MILITARY EXPERIENCE:**  
  
---  
  
"I've been to war, if that's what you are asking." Patient refused to elaborate.  
  
**EMPLOYMENT HISTORY:**  
  
---  
  
Patient reports the following employment history: Patient formerly employed at same school for over a decade and a half. .

Patient reports the following difficulties/problems in vocational endeavors: "I was sacked." Patient declines to give details.

Patient identifies the following unmet employment needs at this time: When asked if he would like a job, he states, "I suppose.".  
  
**LEGAL HISTORY**  
  
---  
  
Patient reports that they have the following legal charges in their history: Patient refused to answer.. 

Patient reports the following jail/prison time served: Patient refused to answer.. 

Patient reports current parole/probation status: Patient refused to answer.. 

Patient reports following involvement with child protective services or similar: Patient refused to answer..

Patient identifies the following unmet legal needs at this time: Patient refused to answer..  
  
**MEDICAL HEALTH AND HISTORY** :   
  
---  
  
Patient identifies the following medication allergies: none. 

Patient identifies the following significant medical issues/diagnoses: Patient discharged from Boston Convalescence Hospital with diagnosis of alcohol-induced pancreatitis..

Patient identifies the following current medications: none

Patient’s most recent medical exam was on or around the following date: 5/25/1998. 

Patients identifies the following medical hospitalizations: 5/23 to 5/25 at Boston Convalescence Hospital. 

Patients identifies the following medical procedures/surgeries: none. 

Patient identifies the following unmet needs with health, nutrition or dental problems? needs primary care doctor  
  
**PSYCHIATRIC HISTORY AND TREATMENT:**

Patient identifies the following reasons for seeking treatment: "It's required.". 

Patient identifies the following historical mental health issues/diagnoses: none

Patient identifies the following historical psychiatric medications: none

Patient identifies the following CURRENT psychiatric medications: none

Patient identifies previous psychiatric hospitalizations: none. 

Patient identifies history of non-inpatient mental health treatment: none

Patient identifies history of other psychiatric treatment: none  
Patient identifies the following unmet needs with mental healt: Patient referred to this clinic due to endorsing suicidal ideation on intake to men's shelter. Patient able to contract for safety and is therefore appropriate for outpatient treatment. Patient agreed to seek ER services if suicidal ideation becomes active. 

  


**TRAUMA**

Patient history of surviving traumatic events is as follows: physical assault, assault w/a weapon, unwanted or uncomfortable sexual experience, combat/exposure to a war zone, life-threatening illness or injury, severe human suffering, sudden violent death e.g. homicide, suicide, serious injury, harm or death you caused to someone else, any other very stressful event/experience. 

Patient identifies the following unmet trauma needs at this time: Patient denies unmet trauma recovery needs at this time., Patient endorses feeling safe in home environment..

  
| 

**RISK ASSESSMENT**  
  
---  
  
**Suicidal and Self-Injury Behavior (past week)**

| 

Patient self-reports recent passive suicidal ideation.  
  
**Suicide Ideation (most severe past week)**

| 

Patient self-reports recent non-specific active suicidal thoughts.  
  
**Activating Events (recent)**

| 

Loss or other significant event, Current or pending isolation, Feeling alone, Unclear exactly, loss of job seems to be primary precipitating event. Patient is reluctant to discuss with greater detail.  
  
**Treatment History**

| 

Not receiving tx  
  
**Clinical status (recent)**

| 

Hopelessness, Major depressive episode, Substance abuse or dependence, Perceived burden on family/others, Chronic physical pain or acude medical issue, Method for suicide available  
  
**Protective factors**

| 

Fear of death or dying due to pain/suffering  
  
  


**HARM OR TRAUMA TO** **SELF** **(past and present)**  
  
---  
| 

**Recent**

| 

**Lifetime**  
  
Patient identifies the following history of passive suicidal ideation: 

| 

Patient self-reports recent passive suicidal ideation.

| 

Patient self-reports lifetime passive suicidal ideation., "Daily."  
  
Patient identifies the following history of non-specific active suicidal ideation: 

| 

Patient self-reports recent non-specific active suicidal thoughts. 

| 

Patient self-reports lifetime history of non-specific active suicidal thoughts., "Frequently."  
  
Patient identifies the following history of Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act: 

| 

"Must you ask?"

| 

"This is growing tiresome."  
  
Patient identifies the following history of Active Suicidal Ideation with Some Intent to Act, without Specific Plan: 

| 

"Isn't this the same question you just asked?"

| 

"Are all these questions strictly necessary?"  
  
Patient identifies the following history of Active Suicidal Ideation with Specific Plan and Intent:

| 

"If you must probe: fine. I stood on the bridge near the shelter yesterday and just thought about letting go. But I didn't want to go back to the hospital for a botched attempt."

| 

"I can't tell you how many moments like that I've endured."   
  
Patient identifies the following history of non-suicidal self harm: 

| 

Patient self-reports recent Non-Suicidal Self-Injurious Behavior, "Drinking myself into a stupor, if that counts." 

| 

Patient self-reports lifetime Non-Suicidal Self-Injurious Behavior, Patient laughed bitterly. "Every day I wake up involves some degree of self-injury."   
  
Patient identifies history of suicide attempts: 

| 

"Does it count if I didn't bother getting myself medical treatment for a life-threatening wound?" 

| 

"I don't want to answer that question."   
  
Patient identifies history of aborted suicide attempts: 

| 

"As I mentioned before, my cowardice stopped me from doing permanent damage, just yesterday." 

| 

"Dozens of times."   
  
Patient identifies history of interrupted suicide attempts: 

| 

"I've never been so stupid as to let on to my plans."

| 

"Just once. And it infuriated the hell out of me."   
  
Patient identifies history of preparatory behavior for a suicide attempt: 

| 

Patient denies history of preparatory behavior for a suicide attempt in past month., "The thoughts come, and I can't be bothered to give a shit."

| 

"I always have had an exit strategy." Patient refused to elaborate.  
  
Most lethal suicide attempt actual damage:

| 

3\. Moderately severe physical damage; "I let myself bleed out after a wound that did not need to be fatal. And yet here I am. Isn't that just... peachy."

| 

3\. Moderately severe physical damage; medical hospitalization and likely intensive care required   
  
Most lethal suicide attempt potential damage:

| 

2 = Behavior likely to result in death despite available medical care

| 

2 = Behavior likely to result in death despite available medical care  
  
**Suicidal Ideation Details**  
  
Intensity of ideation: 

| 

Active Suicidal Ideation with Specific Plan and Intent, "I do nothing but plan." Patient refuses to elaborate.

| 

Active Suicidal Ideation with Specific Plan and Intent, Patient acknowledges history but refused to elaborate.  
  
Frequency of ideation:

| 

Many times each day

| 

Many times each day  
  
Duration of ideation:

| 

4-8 hours / most of the day, "It only goes away when I'm bloody soused."

| 

more than 8 hours / persistent or continuous.  
  
Controllability of ideation: 

| 

Does not attempt to control thoughts, "Why bother at this point. My constant thought is: I ought to just take out the rubbish."

| 

Can control thoughts with a lot of difficulty, "When I had to control it, I did."   
  
Deterrents to ideation:

| 

Patient self-reports that recently, deterrents probably did not stop them from attempting suicide., "The only thing stopping me now is cowardice."

| 

Patient self-reports that at their worst, deterrents definitely stopped them from attempting suicide., "I had a job to do. I did it."  
  
Reasons for ideation: 

| 

Patient self-reports that recent reasons for wanting to be dead were Completely to end or stop the pain (patient couldn’t go on living how feeling)

| 

Patient self-reports that at their worst, reasons for wanting to be dead were Completely to end or stop the pain (patient couldn’t go on living how feeling)  
  
Patient identifies reasons for living: 

| 

"I don't have a reason to stay alive now. The only reason I’m even here is because someone must have thought my dying wish was to go to a ruddy Aerosmith concert. Damn fool seems to not know the definition of sarcasm.” 

| 

Family, Spiritual reasons, "I don't have those reasons anymore."  
  
  
  


**HARM OR TRAUMA TO** **OTHERS** **(past and present)**

Patient identifies the following history of harming others: Patient laughed but refused to go into detail. 

Patient identifies the following history of anger management concerns: "Oh, I'm sure I could use some manner of anger management treatment.".

Patient identifies the following unmet needs at this time: "I'm sure I would benefit if that's what you deem appropriate.".  
  
**SUBSTANCE ABUSE HISTORY AND TREATMENT:**  
  
---  
  
Patient identifies the following history of abuse of drugs/alcohol: "I enjoy how I feel when I’m drunk, and I don't plan to stop."

Patient identifies the following history of drug/alcohol treatment before: Patient denies history of substance use treatment. 

Patient identifies the following unmet substance use needs at this time: Patient denies needs for substance use treatment..  
  
**SOCIAL FUNCTIONING:**  
  
---  
  
Patient identifies the following social relationships: Fraught relationships with coworkers, Fraught relationships with neighbors, Fraught relationships with community members, Does not feel there are at least 1-2 people they can talk about issues in their life, Patient reportedly keeps to himself at the shelter, as per case manager. 

Patient identifies the following unmet social needs at this time: Patient denies needs in the area of social functioning..  
  
**SEXUALITY/SEXUAL IDENTITY:**  
  
---  
  
Patient identifies with the following sexual orientation: "I prefer women, but never have been in a position to be choosy."

Patient identifies with the following gender orientation: Patient presents as male; patient just scoffed when asked gender.

Patient identifies the following problems related to either gender/sexual orientation: "I've never felt particularly attached to being male. Doesn't matter anyway, though."   
  
**CULTURAL:**

Patient identifies the following cultural beliefs / practices important to them: Patient denies significant cultural beliefs or practices  
  
---  
  
Patient identifies with the following racial/ethnic background: White, Not Hispanic

Patient identifies the following needs related to culture, race, or ethnic background: Patient denies having any needs related to culture, race, or ethnic identity  
  
**SPIRITUALITY:**  
  
---  
  
Patient identifies the following spiritual beliefs / practices / faith tradition important to them: Pagan, "My faith wouldn't be comprehensible to you."

Patient identifies the following spiritual background: Patient denies having any needs related to spiritual beliefs / practices / faith tradition  
  
  
  
**Patient STATED NEED FOR SERVICES/IMMEDIATE GOALS** : 

Patient identifies a desire to achieve the following goals in order to successfully complete treatment: "If I'm not actually going to bother killing myself, I might as well figure out how to survive without being in this much pain."

Patient identifies they have the following personal strengths: "I've always prided myself upon my intelligence."

Patient identifies other changes they want to make in their life: "I don't want to hurt anymore." 

Patient identifies the following concrete needs: Housing, income (employment), decreased substance use 

Patient motivation to engage in treatment: "Worst case scenario, I can always kill myself later.".   
  
---  
  


**CLINICAL SUMMARY/DIAGNOSES**

Based on this clinician’s assessment, patient is recommended to receive the following modes of treatment and intervention: individual interpersonal therapy, medication management, substance use counseling, cognitive behavioral therapy methods, crisis management/safety planning. According to the above assessment, patient meets the clinical criteria for the following mental health diagnoses: Major Depressive Disorder, Substance use disorder. Patient’s current stage of change is estimated to be: Contemplation.. Patient’s criteria for discharge are as follows: patient will be better able to manage depression symptoms, patient will be able to use self-help and coping strategies effectively without prompting/support, patient will reduce incidence, frequency, duration, and severity of suicidal ideation and increase controllability and effectiveness of deterrents to suicide, patient will desire discharge from services, patient will achieve goals of treatment to their satisfaction. Treatment duration is estimated to be 1 year or more.   
  
**STAFF SIGNATURE and TITLE/CREDENTIAL:** **  
  
**

Leticia Rosenberg, LICSW; LADC  
  


  


  
  


| 

**DATE COMPLETED:** **  
  
**

5/27/1998  
  
---|---  
|   
  
  
  
  
  



	2. 6/22/1998

**Severus, S. DOB 1/9/1960.**

**Date of Encounter: 6/22/1998 at 5:00:00 PM**

Clinician: Leticia Rosenberg, LICSW

Boston Institute for Family Therapeutics LLC 

**PHQ9: Lack of motivation? 3 Down depressed hopeless? 3 Burden on others? 3 Concentration issues? 0 Energy issues? 3 Sleep issues? 3 Appetite issues? 3 Moving faster or slower than usual? 3 Better off dead / hurting self? 3. Total PHQ9: 23**

**GAD7: Nervous anxious on edge? 3 Unable control worrying? 3 Worrying too much different things? 3 Trouble relaxing? 3 Being so restless hard to sit still? 3 Easily annoyed or irritable? 3 Feeling like something awful’s going to happen? 1 Total GAD7: 19**

Clinician met with patient at office. Patient endorsed active suicidal ideation (intent, method, and plan). Patient endorsed passive homicidal ideation. Patient identified chronic feelings of unsafety; to be expected with PTSD symptoms. With regards to self-harm, he endorses that he's been drinking excessively with intent to self-harm since mid-May. (As noted before, patient indicates mid-May is when he resigned from employment with the private school where he worked as a chemistry teacher). 

Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: reluctant. Patient motivation for change was reluctant. Throughout session, patient was able to engage in goals set on treatment plan. 

Patient reports he was started on fluoxetine 10mg on 6/19/2020 after initial visit with psychiatric provider, F. Crane MD. 

Focus of Session: Patient indicated having the following significant events since last session: Patient identifies since last session, he has began to cut down on his drinking. "It's not doing me any favors," he observes. Unexpectedly to this clinician, patient reports he has begun employment as a private researcher for a large biopharmaceutical institution.

Patient identifies "It seems if I'm too much a coward to kill myself, I had better find some way to keep my miserable hide alive." Clinician validated this progress. Patient declined to speak about his former love interest this session; he seems to have regretted disclosing this during previous session. Patient seems to have put up guard again with this clinician despite previous week's breakthrough. 

Clinician completed the following psychometric assessment with patient: PHQ9, GAD7 and patient scored positive for depression and positive for anxiety. 

Clinician observed the following about the patient during the session: Patient was well groomed, Patient seemed disengaged and aloof, Patient seemed skeptical and suspicious.

Clinician assisted patient in the following: providing encouragement and emotional support to patient, providing emotional validation for patient's experiences, naming feelings, challenging negative self-talk, developing new strategies to cope with adversity in patient's life. Clinician utilized the following interventions: reviewing safety / crisis plan, rolling with resistance (Motivational Interviewing skill), asking open-ended questions (Motivational Interviewing skill), supporting self-efficacy and optimism, adjusting to client resistance rather than opposing it directly (Motivational Interviewing skill).

Clinician identified the following barriers to patient progress towards objectives: patient lack of emotional strength and resources, patient feelings of inadequacy and low self-esteem, patient despair and depression, patient's stage of change. During the session, clinician and patient decided to continue current treatment plan. Patient responded to clinician’s interventions in the following ways: indifferently.

Together, the patient and clinician worked towards the following treatment goal during the session: decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms. The clinician recommended patient do the following between sessions: reviewing safety plan in moments of emotional distress, thinking about observations offered by therapist during the session, practicing noticing somatized emotions in body. 

Plan: Clinician and patient plan to meet for next session scheduled for: 6/29/1998. Clinician to remain available ongoing and will follow up as needed. 


	3. 6/29/1998

**Severus, S. DOB 1/9/1960.**

**Date of Encounter: 6/29/1998 at 5:00:00 PM**

Clinician: Leticia Rosenberg, LICSW

Boston Institute for Family Therapeutics LLC 

**PHQ9: Lack of motivation? 3 Down depressed hopeless? 3 Burden on others? 3 Concentration issues? 0 Energy issues? 3 Sleep issues? 2 Appetite issues? 1 Moving faster or slower than usual? 3 Better off dead / hurting self? 3. Total PHQ9: 21**

**GAD7: Nervous anxious on edge? 3 Unable control worrying? 0 Worrying too much different things? 3 Trouble relaxing? 3 Being so restless hard to sit still? 3 Easily annoyed or irritable? 3 Feeling like something awful’s going to happen? 0 Total GAD7: 15**

Clinician met with patient in office. Patient endorsed active suicidal ideation (fleeting thoughts). Patient denied homicidal ideation. Patient denied safety concerns. Patient has decreased binge drinking behaviors.. Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: adequate. Patient motivation for change was reluctant. Throughout session, patient was able to engage in goals set on treatment plan. 

**Focus of Session:** Patient indicated having the following significant events since last session: Patient reports he has stopped drinking in mornings. "But I can't sleep without at least a few pints." Patient seems meticulously clean and tidy today, though impatient, excessive tapping of foot during session while SW writes notes. He seems especially irritable today. 

Patient described the following progress in relationships of significance: Patient is contemptuous of his supervisor at work. "It's not my fault that I get my work done faster than any other tech." He reports the activities of his work include moving samples using pipettes. SW observed this sounds like surprisingly low-level work for individual with his education; patient reports snarlingly, "Well, one has to work one's way up the chain, doesn't one?" He seemed very frustrated with this clinician today. SW observed it might have something to do with patient's craving for alcohol being out of control. Patient at first denied this, stood up and roared at clinician to "stop being such an infernal busybody." 

SW suggested patient leave the room to bathroom to compose himself; patient returned extremely apologetic. He described his former employer's excessive "harping" on patient's alcohol use, even during personal time off-work. "He knew I could handle it, but he still saw the need to accuse and shame me. It's not like I had any friends to unburden myself to. What else was I supposed to do but find comfort in a bottle?" 

Patient acknowledged that he has only ever had two bosses in his life, and neither of them was particularly interested in his actual tea ching duties. "They were far more concerned with the war." Patient identified that he was simultaneously working as a covert agent while also holding a full-time courseload as a middle and high school teacher and completing scientific research for private contracts. [Note: While this sounds grandiose and farfetched, SW has yet to determine if this is delusional thinking or not. Patient's presentation is credible, and as far as SW knows, patient is reliable historian.] 

SW observed patient must have been magic in order to manage that kind of workload - for almost twenty years, he reports. "You might say that," he said, as if he were having some private joke. He also explained "I have chronic insomnia anyway - and anytime that failed me, there was always a supply of purple hearts." [SW researched and learned after the fact that this was in fact a reference to Drexamyl, an amphetamine]. 

Patient identified need for the following resources from clinician: Patient expressed anger with clinician, and was able to accept the connections between SW's probing and triggers related to his past employment. Patient able to reflect thoughtfully about his past and how it relates to his present.

**Clinician completed the following psychometric assessment with patient: PHQ9, GAD7 and patient scored positive for depression and positive for anxiety.** Clinician observed the following about the patient during the session: Patient was interested and intellectually curious, Patient was well groomed, Patient seemed nervous and preoccupied, Patient seemed skeptical and suspicious. 

Clinician assisted patient in the following: providing encouragement and emotional support to patient, reflecting and summarizing patient concerns, providing emotional validation for patient's experiences, naming feelings, identifying patterns in patient's life, building rapport and engagement in treatment, Encouraging a nonjudgmental, collaborative relationship. 

Clinician utilized the following interventions: rolling with resistance (Motivational Interviewing skill), asking open-ended questions (Motivational Interviewing skill), supporting self-efficacy and optimism, adjusting to client resistance rather than opposing it directly (Motivational Interviewing skill). 

Clinician identified the following barriers to patient progress towards objectives: patient feelings of inadequacy and low self-esteem, patient despair and depression, patient's stage of change. During the session, clinician and patient decided to continue current treatment plan. Patient responded to clinician’s interventions in the following ways: positively. Together, the patient and clinician worked towards the following treatment goal during the session: decreasing incidence and severity of interpersonal conflict at home/work, decreasing incidence and severity of emotional dysregulation and distress symptoms. The clinician recommended patient do the following between sessions: reviewing safety plan in moments of emotional distress, thinking about observations offered by therapist during the session, attending next scheduled session. 

Plan: Clinician and patient plan to meet for next session scheduled for: 7/6/1998. Clinician to remain available ongoing and will follow up as needed. 


	4. Chapter 4

**Severus, S. DOB 1/9/1960.**

**Date of Encounter:7/6/1998 at 5:00:00 PM**

**Clinician: Leticia Rosenberg, LICSW**

**Boston Institute for Family Therapeutics LLC**

  
  


**PHQ9: Lack of motivation? 3 Down depressed hopeless? 3 Burden on others? 3 Concentration issues? 0 Energy issues? 0 Sleep issues? 3 Appetite issues? 3 Moving faster or slower than usual? 3 Better off dead / hurting self? 2. Total PHQ9: 18**

**GAD7: Nervous anxious on edge? 3 Unable control worrying? 0 Worrying too much different things? 3 Trouble relaxing? 3 Being so restless hard to sit still? 3 Easily annoyed or irritable? 3 Feeling like something awful’s going to happen? 0 Total GAD7: 15**

Clinician met with patient. Patient endorsed active suicidal ideation (fleeting thoughts). Patient denied homicidal ideation. Patient denied safety concerns. Patient continues to drink after returning to shelter from work.. Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: reluctant. Patient motivation for change was reluctant. Throughout session, patient was able to engage in goals set on treatment plan. 

Focus of Session: Patient indicated having the following significant events since last session: Patient seemed less standoffish this session. Patient endorsed feeling more stable at new job, and indicates he appreciates SW’s intervention from previous week. “I didn’t realize how much my emotions were getting the best of me.” 

Patient acknowledged that he felt somewhat more optimistic about therapy than previous sessions. “Perhaps there’s something to this business.” However as SW attempted to provide psychoeducation regarding therapy and process, patient seemed to shut down visibly, with eyes Downcast and head lowered. Patient denied further frustrations with his supervisor since last week. “He’s a dunderhead but I must simply accept that I hold myself to a higher standard than most.”

SW and patient discussed how this is both an advantage and disadvantage, to have such high standards for behavior. 

Patient described the following progress in relationships of significance: Patient seemed almost receptive to talk about the romantic situation he delved into a few sessions prior. “She was the love of my life,” he acknowledged and sounded bitter and resentful. His eyes were narrowed and his face impassive, constricted affect. “I just didn’t have the good sense to know that there’s nothing else worth living for.” 

Patient and SW discussed in somewhat opaque language how love is primary motivator for patient, in terms of his behavior up until recently. Patient was very aversive to providing details as usual, but I gather this is in reference to the woman whose son patient purports to have saved the life of. Patient identified that he is currently struggling with identifying some kind of meaning in his life now that the child of his former love interest is an adult no longer requiring protection. 

Patient seems disinclined to consider his own happiness being worthwhile to work towards. “Quite simply, I don’t deserve it.”

Patient identified need for the following resources from clinician: Patient disclosed feeling “incredibly jealous” growing up of his love interest. “They weren’t rich by any stretch of the imagination. But to me, she had everything I ever wanted in life. Love from both parents, food always on the table, a sister who could understand even if she was a bit nasty, pretty clothes, and natural beauty. I felt like a shadow in comparison, the moon to her sunshine. There was nothing more perfect I could imagine than Lily Evans, and I was and still remain incredibly jealous of the gifts she was given at birth.” SW asked patient about which of these things felt most achievable to him. He laughed aloud. “Oddly enough, beauty. I can clean up well when I want to.” He seemed privately amused by this but did not respond to probing questions.. 

**Clinician completed the following psychometric assessment with patient: PHQ9, GAD7 and patient scored positive for depression and positive for anxiety.** Clinician observed the following about the patient during the session: Patient was interested and intellectually curious, Patient seemed nervous and preoccupied, Patient seemed skeptical and suspicious. Clinician assisted patient in the following: providing encouragement and emotional support to patient, reflecting and summarizing patient concerns, providing emotional validation for patient's experiences, exploring patient strengths and weaknesses, building rapport and engagement in treatment, Encouraging a nonjudgmental, collaborative relationship. 

Clinician utilized the following interventions: providing empowerment-focused psychoeducation, providing mental health psychoeducation, completing psychometric assessment to assess patient condition severity, supporting self-efficacy and optimism. Clinician identified the following barriers to patient progress towards objectives: patient current life circumstances outside of their control, patient lack of emotional strength and resources, patient feelings of inadequacy and low self-esteem, patient despair and depression. During the session, clinician and patient decided to continue current treatment plan. Patient responded to clinician’s interventions in the following ways: positively. 

Together, the patient and clinician worked towards the following treatment goal during the session: decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing independence and ability to self-actualize patient's goals. The clinician recommended patient do the following between sessions: writing down goals to discuss for next session in advance, reviewing safety plan in moments of emotional distress, thinking about observations offered by therapist during the session, attending next scheduled session. 

Plan: Clinician and patient plan to meet for next session scheduled for: 7/13/1998. Clinician to remain available ongoing and will follow up as needed. 


	5. Chapter 5

**Severus S  
DOB 1/9/1960.  
Date of Encounter: 7/13/1998 5:00:00 PM   
** **Clinician: Leticia Rosenberg, LICSW**

**Boston Institute for Family Therapeutics LLC**

**PHQ9: Lack of motivation? 3 Down depressed hopeless? 3 Burden on others? 3 Concentration issues? 0 Energy issues? 3 Sleep issues? 3 Appetite issues? 3 Moving faster or slower than usual? 3 Better off dead / hurting self? 3. Total PHQ9: 21**

**GAD7: Nervous anxious on edge? 3 Unable control worrying? 0 Worrying too much different things? 0 Trouble relaxing? 3 Being so restless hard to sit still? 3 Easily annoyed or irritable? 3 Feeling like something awful’s going to happen? 0 Total GAD7: 12**

Clinician met with patient. Patient endorsed active suicidal ideation (fleeting thoughts). Patient endorsed active homicidal ideation (fleeting thoughts). Patient denied safety concerns. denied recent self harm behaviors. Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: adequate. Patient motivation for change was reluctant. Throughout session, patient was able to engage in goals set on treatment plan.

Focus of Session: Patient indicated having the following significant events since last session: Patient identifies he has been "flirting with the idea" of killing his supervisor at work. (escalation of ideation). Patient identifies also feeling increasingly suicidal. "It seems like I can't escape the same old patterns of my life." He reflects that he has no new ideation methods in mind.

Patient described the following progress in relationships of significance: SW and patient discussed relationships with former supervisors: Tom and Al. "Tom was a menace to society, but in another way, so was...Al. Both of them wanted their ideology to dominate. Neither could rest while the other existed. I don't know why they cared so much about what everyone else thought and did. I've never been one for caring too much about what other people think of me, aside insofar as was necessary for survival. Tom and Al... they were obsessed."

Patient indicates that he feels responsible for the death of Al, stating about himself "It was euthanasia, and at his request, but at my hand." Clinician reflected pt's guilt and shame and challenged it, though pt was not receptive to this intervention. Pt also discussed his relationship with Tom as being somewhat complicated. "He never knew for certain that I wasn't on his team, so to speak. I played both sides beautifully, but it was dancing at the edge of a knife's blade."

SW reflected that pt probably was good at this dance, and pt colored a bit red. He seemed uneasy with such a mild compliment.. Patient identified need for the following resources from clinician: SW reflected back positive regard and offered pt encouragement, empathy, and attentive listening.. 

**Clinician completed the following psychometric assessment with patient: PHQ9, GAD7 and patient scored positive for depression and positive for anxiety.** Clinician observed the following about the patient during the session: Patient was interested and intellectually curious, Patient was well groomed, Patient appeared fatigued and exhausted, Patient seemed nervous and preoccupied.

Clinician assisted patient in the following: providing encouragement and emotional support to patient, reflecting and summarizing patient concerns, providing emotional validation for patient's experiences, challenging negative self-talk, identifying patterns in patient's life, Encouraging a nonjudgmental, collaborative relationship, Communicating respect for and acceptance of patient and their feelings, encouraging patient to dismiss self-reproach and guilt/shame responses.

Clinician utilized the following interventions: providing empowerment-focused psychoeducation, providing mental health psychoeducation, completing psychometric assessment to assess patient condition severity, rolling with resistance (Motivational Interviewing skill), asking open-ended questions (Motivational Interviewing skill), supporting self-efficacy and optimism.

Clinician identified the following barriers to patient progress towards objectives: patient current life circumstances outside of their control, patient lack of emotional strength and resources, patient despair and depression.

During the session, clinician and patient decided to continue current treatment plan. Patient responded to clinician’s interventions in the following ways: indifferently.

Together, the patient and clinician worked towards the following treatment goal during the session: decreasing incidence and severity of anxiety symptoms, decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing patient self-esteem and sense of self-worth.

The clinician recommended patient do the following between sessions: writing down goals to discuss for next session in advance, thinking about observations offered by therapist during the session, journaling about feelings over the course of the week, practicing noticing the way particular relationship patterns are positively or negatively reinforced. 

Plan: Clinician and patient plan to meet for next session scheduled for: 7/20/1998. Clinician to remain available ongoing and will follow up as needed. 


	6. Chapter 6

**Severus S 7/20/1998 5:00 PM**

Clinician: Leticia Rosenberg, LICSW

Boston Institute for Family Therapeutics LLC 

**PHQ9: Lack of motivation? 3 Down depressed hopeless? 3 Burden on others? 3 Concentration issues? 3 Energy issues? 3 Sleep issues? 3 Appetite issues? 3 Moving faster or slower than usual? 3 Better off dead / hurting self? 3. Total PHQ9: 27**

**GAD7: Nervous anxious on edge? 3 Unable control worrying? 3 Worrying too much different things? 3 Trouble relaxing? 3 Being so restless hard to sit still? 3 Easily annoyed or irritable? 3 Feeling like something awful’s going to happen? 3 Total GAD7: 21**

Clinician met with patient in office. Patient endorsed active suicidal ideation (intent, method, and plan). Details: patient identifies having planned to slit his wrists in the shower at the shelter with a shaving razor but only stopped because the male staff member assigned to his unit wasn't in that day, and instead it was a female staff member supervising. Pt states "I didn't want her to have to see this." He gestured to his body as if to suggest he is a monstrous sight to behold. SW will discuss body image issues with pt on later date when he has returned to baseline. (Method and Plan, but no actual attempt made). 

Patient denied homicidal ideation. Patient denied safety concerns. denied recent self harm behaviors. Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: desperate. Patient motivation for change was desperate, but help-rejecting. Throughout session, patient was pt despairing about treatment at this time to engage in goals set on treatment plan.

Focus of Session: Patient indicated having the following significant events since last session: Patient showed up today completely disheveled, malodorous and smelling of alcohol. "I'm responsible for the deaths of children. Plural. What sad excuse do I have to stay in this world?" 

Pt's case manager Betsy Loran called SW today prior to pt's session to check in on progress with pt; consent is on file. Ms. Loran stated that pt did not attend work today, and that he was drinking and moody all weekend. SW inquired about this with patient. 

Due to shelter restrictions regarding alcohol consumption, pt reports he was drinking in public park and was arrested for such. However it seems no charges were filed, as per pt, "I didn't even have to give them my information." He seemed privately amused at that, and SW inquired about why he might find that funny. Pt indicated "I have my methods of persuasion," and SW inquired if those means were sexual. Pt seemed deeply offended and remained silent for several minutes, staring intensely at this clinician. When he spoke again, it was to discuss another topic. 

Patient described the following progress in relationships of significance: Pt seemed disinclined to discuss specifics with this worker, as per usual, and instead spoke in grandiose terms about his involvement in war. "I am responsible for the deaths of so many," pt said, with apparent regret. "I wish there had been another way. It doesn't matter, though, because I still did it. Intent does not negate impact."

SW encouraged patient to try and rerame these thoughts; based on previous discussions, pt was under power of two very intelligent and powerful employers and pt was under a psychological hold with them. Pt seemed to accept this, at least to a limited extent. "Perhaps so, though I want to believe that I had a choice." SW educated pt about gaslighting behaviors and narcissistic abuse. Pt seemed intrigued by this discussion and seemed relieved by end of session. Pt stated that he still "feels awful" and denies improvement in depression symptoms despite pt's apparent mood improvement. 

Patient identified need for the following resources from clinician: Pt seemed despairing at beginning of tx session and had active suicidal thoughts. Pt was able to contract for safety and agreed to seek emergency services in the event that he is not safe.

Pt indicated he will not be drinking in public parks again any time soon, though he reports he is struggling to discontinue alcohol abuse at this time. Pt promised to attend work as scheduled tomorrow and that he would endeavor to avoid drinking the rest of the week, at least to excess.. 

**Clinician completed the following psychometric assessment with patient: PHQ9, GAD7 and patient scored positive for depression and positive for anxiety.** Clinician observed the following about the patient during the session: Patient was disheveled and poorly groomed, Patient appeared fatigued and exhausted, Patient seemed overwhelmed and stressed, Patient seemed skeptical and suspicious.

Clinician assisted patient in the following: providing encouragement and emotional support to patient, providing emotional validation for patient's experiences, challenging negative self-talk, identifying patterns in patient's life, identifying unmet needs in patient's life, building rapport and engagement in treatment, Encouraging a nonjudgmental, collaborative relationship, Communicating respect for and acceptance of patient and their feelings, encouraging patient to dismiss self-reproach and guilt/shame responses.

Clinician utilized the following interventions: reviewing safety / crisis plan, providing mental health psychoeducation, completing psychometric assessment to assess patient condition severity, rolling with resistance (Motivational Interviewing skill), asking open-ended questions (Motivational Interviewing skill), supporting self-efficacy and optimism, adjusting to client resistance rather than opposing it directly (Motivational Interviewing skill).

Clinician identified the following barriers to patient progress towards objectives: patient current life circumstances outside of their control, patient feelings of inadequacy and low self-esteem, patient despair and depression, patient's stage of change, patient's challenges with insight into their condition. During the session, clinician and patient decided to continue current treatment plan.

Patient responded to clinician’s interventions in the following ways: positively, denied positive reaction but visibly improved in terms of affect. Together, the patient and clinician worked towards the following treatment goal during the session: decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing patient self-esteem and sense of self-worth. The clinician recommended patient do the following between sessions: reviewing safety plan in moments of emotional distress, reading about new concept, outreaching to clinician for crisis call as needed, attending next scheduled session. 

Plan: Clinician and patient plan to meet for next session scheduled for: 7/27/1998. Clinician to remain available ongoing and will follow up as needed. 


	7. Chapter 7

**Severus S** **DOB 1/9/1960.**

 **Date of Encounter:** **7/27/1998 5:00:00 PM**

Clinician: Leticia Rosenberg, LICSW

Boston Institute for Family Therapeutics LLC 

**PHQ9: Lack of motivation? 3 Down depressed hopeless? 3 Burden on others? 3 Concentration issues? 3 Energy issues? 0 Sleep issues? 0 Appetite issues? 3 Moving faster or slower than usual? 3 Better off dead / hurting self? 3. Total PHQ9: 21**

**GAD7: Nervous anxious on edge? 3 Unable control worrying? 3 Worrying too much different things? 3 Trouble relaxing? 3 Being so restless hard to sit still? 3 Easily annoyed or irritable? 3 Feeling like something awful’s going to happen? 3 Total GAD7: 21**

Clinician met with patient in office. Patient endorsed active suicidal ideation (intent, method, and plan). Patient denied homicidal ideation. Patient patient indicates he is unable to contract for safety this session. patient describes having pounded his head against the shower wall today in an attempt to 'break my sodding skull' but only succeeded in bruising himself due to being interrupted by men's shelter supervisor. 

Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: despairing. Patient motivation for change was: none. Patient desires to be dead and is unable to contract for safety. Throughout session, patient was unable to engage in goals set on treatment plan.

 **Focus of Session:** Patient indicated having the following significant events since last session: Patient and SW discussed patient's large bruise on head. He indicated that he attempted to 'break open my sodding skull' but denies to answer whether it was a suicide attempt or not. "I just need the thoughts to be gone." Patient endorses feeling "a normal amount" of energy, and denies sleep issues. "I slept my normal four hours."

Patient unable to contract for safety during this session. Patient was taken via EMS to Boston Convalescence Hospital psychiatric unit, floor 7. 

**Patient described the following progress in relationships of significance:** SW pointed out previous self-harm ideation occurred during showering last week. Patient identified "water and me, generally don't mix," and was able to articulate "there's some... trouble that happened when I was a child, in the bath." Patient did not elaborate, but the patient stared pointedly into SW's eyes.

SW suspicious of possible sexual abuse in history. Pt refused to answer when SW probed regarding this. 

He remained unresponsive and mute for a few minutes as well, apparently dissociating. Patient seems to have some self-awareness of this, and apologized, "Where was I?" though he seemed not to realize how long a time he was dissociated. He seemed uncomfortable when SW pointed out it was over 60 seconds he was absent from conversation. 

SW inquired about suicidal ideation. Patient described possible method for attempting suicide: "I'm just thinking about, how after I leave here, what I should do." "I should end it all, stop being such a bloody wanker." "It would be simplest to get in front of a lorry on the highway. I don't need any further excuses." "I do feel like I ought to be dead. Greater men have been shot for far less, particularly on this side of the pond." 

**Patient identified need for the following resources from clinician:** SW connected pt's previous self-harm behaviors / ideations to most recent self-harm episode. Pt endorsed suicidal ideation, endorsed plan, and endorsed method. "I don't know how to end these demons otherwise."

Patient seemed listless and submissive, refusing to make any decisions regarding his care. He shrugged instead of being able to contract for safety or endorse self-preservation desires. Pt did not resist when SW called EMS for pt to be removed to psychiatric inpatient admission. 

**Clinician completed the following psychometric assessment with patient: PHQ9, GAD7 and patient scored positive for depression and positive for anxiety.** Clinician observed the following about the patient during the session: Patient was disheveled and poorly groomed, Patient appeared fatigued and exhausted, Patient seemed overwhelmed and stressed, Patient seemed lethargic, Patient was withdrawn and monosybillic.

 **Clinician assisted patient in the following:** providing emotional validation for patient's experiences, identifying patterns in patient's life, exploring patient strengths and weaknesses, educating patient about treatment options, building rapport and engagement in treatment, assessing patient progress towards goals, evaluating patient's values and patient's engagement in meaningful activities, encouraging patient to dismiss self-reproach and guilt/shame responses, providing ideas on how to resolve a disconnect between cognitive expectations and emotional reality (head and heart), identifying underlying feelings beneath 'feeling numb' or disconnected.

 **Clinician utilized the following interventions:** prompting collaborative problem-solving skills, providing mental health psychoeducation, completing psychometric assessment to assess patient condition severity, asking open-ended questions (Motivational Interviewing skill), supporting self-efficacy and optimism, observing the connection between thoughts, feelings, and behaviors (cognitive behavioral therapy methods).

 **Clinician identified the following barriers to patient progress towards objectives:** patient lack of emotional strength and resources, patient despair and depression, patient's being overwhelmed by unmet concrete needs, patient's challenges with insight into their condition. During the session, clinician and patient decided to continue current treatment plan.

 **Patient responded to clinician’s interventions in the following ways:** indifferently.

 **Together, the patient and clinician worked towards the following treatment goal during the session:** decreasing incidence and severity of anxiety symptoms, decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing patient self-esteem and sense of self-worth.

The clinician recommended patient do the following between sessions: thinking about observations offered by therapist during the session, following up with new resource, outreaching to clinician for crisis call as needed, attending next scheduled session, practicing noticing the way particular relationship patterns are positively or negatively reinforced. 

**Plan:** Clinician and patient plan to meet for next session scheduled for: 8/3/1998 or the week after, pending pt's discharge from hospital. Clinician to remain available ongoing and will follow up as needed. Clinician notified Frasier Crane MD regarding pt's inpatient admission; plan is to d/c fluoxetine given pt has been on 10mg for just over 4 weeks prior to this escalation in symptoms.

Dr Crane will coordinate pt's care w/inpatient psychiatrist. Pt will also be scheduled for follow up medication visit with Dr Crane once he is discharged from hospital.


	8. Chapter 8

**Severus S** **DOB 1/9/1960.**

**Date of Encounter: 8/10/1998 5:00:00 PM**

Clinician: Leticia Rosenberg, LICSW

Boston Institute for Family Therapeutics LLC 

**PHQ9: Lack of motivation? 3 Down depressed hopeless? 2 Burden on others? 1 Concentration issues? 2 Energy issues? 3 Sleep issues? 3 Appetite issues? 3 Moving faster or slower than usual? 3 Better off dead / hurting self? 1. Total PHQ9: 21**

**GAD7: Nervous anxious on edge? 2 Unable control worrying? 1 Worrying too much different things? 0 Trouble relaxing? 0 Being so restless hard to sit still? 1 Easily annoyed or irritable? 3 Feeling like something awful’s going to happen? 1 Total GAD7: 8**

Clinician met with patient in office. Patient endorsed passive suicidal ideation. Patient denied homicidal ideation. Patient denied safety concerns. denied recent self harm behaviors. Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: adequate. Patient motivation for change was adequate. Throughout session, patient was able to engage in goals set on treatment plan. 

**Focus of Session:** Patient indicated having the following significant events since last session: Pt was discharged from Boston Convalescence Hospital on 8/7/2020. Patient was discontinued off fluoxetine and started on sertraline and buspirone. Patient reports increased appetite "I feel like a teenager in relation to that."

Patient reports increased sleep as well. Patient seems flummoxed by this; "I can't say I like how much time I'm spending sleeping. It feels like a waste." Patient did acknowledge waking up feeling very refreshed after 6.5 hours of sleep and reporting positive improvements in mood on days he sleeps up to 8 hours. Pt was reluctant to acknowledge quality of life improvement. He keeps perserverating on the quantity of wake time having decreased. SW will continue to explore with him. 

Pt resumed work today; despite his trip to inpatient his employer was understanding and did not terminate his employment. Patient reluctantly endorsed gratitude for this, when SW pointed this out.. 

**Patient described the following progress in relationships of significance:** Pt reports that the suicidal ideation "continues to lurk in the darkest recesses of my mind," but acknowledges it no longer is a primary feature that impedes his day. "The thoughts come, and then they go again." Patient acknowledged feeling somewhat improved with this regard, "but I can't help but feel there's something deeply missing. It feels like a loose tooth, and that you keep worrying the gap, you're so used to the discomfort of it being there." 

**Patient identified need for the following resources from clinician:** SW acknowledged pt's progress in the hospital, and validated patient's concerns about appetite. Pt indicates feeling somewhat worried about gaining weight, "I know my metabolism isn't that of a teenager." SW validated patient's concern and provided psychoeducation regarding antidepressants having some mild possibility of weight gain; patient seemed to have strong feelings but denied an interest in exploring them. "Some other time, I might." 

Patient did open up a bit about his feelings of being in the psychiatric inpatient setting: "I hated that feeling of being trapped, and they had to put me in isolation periodically for my temper to cool. But once I stopped fighting the instinct to gnash my teeth, I began to feel peaceful. There was nothing I could do but accept the situation. So that's what I did, and it felt... odd... but it made the process smoother." 

SW validated patient seemed to be proud, and he lowered his head and seemed to hide behind his long hair at the suggestion. "Perhaps," he acknowledged but seemed to withdraw again at the observation. 

SW pointed out patient has intense difficulty when the spotlight is on him, so to speak, and his behavior is being scrutinized. Patient identified relationship to his late father; "It was better not to be noticed at home. I've never been comfortable except in the shadows." 

SW validated patient's willingness to come out into sunshine at least a little bit, which made patient smile slightly. (A rare sight!). SW will revise tx plan w/patient next week (90 day review).

Clinician completed the following psychometric assessment with patient: PHQ9, GAD7 and patient scored positive for depression and positive for anxiety.  Clinician observed the following about the patient during the session: Patient was interested and intellectually curious, Patient was well groomed, Patient seemed lethargic, more cooperative than usual. 

C linician assisted patient in the following: providing encouragement and emotional support to patient, reflecting and summarizing patient concerns, providing emotional validation for patient's experiences, identifying patterns in patient's life, identifying unmet needs in patient's life, building rapport and engagement in treatment, Encouraging a nonjudgmental, collaborative relationship, Communicating respect for and acceptance of patient and their feelings. 

Clinician utilized the following interventions: providing mental health psychoeducation, rolling with resistance (Motivational Interviewing skill), asking open-ended questions (Motivational Interviewing skill), supporting self-efficacy and optimism, Developing discrepancy between clients' goals or values and their current behavior (Motivational Interviewing skill), observing the connection between thoughts, feelings, and behaviors (cognitive behavioral therapy methods). 

Clinician identified the following barriers to patient progress towards objectives: patient current life circumstances outside of their control, patient feelings of inadequacy and low self-esteem, patient despair and depression. 

During the session, clinician and patient decided to continue current treatment plan. Patient responded to clinician’s interventions in the following ways: positively.  Together, the patient and clinician worked towards the following treatment goal during the session: decreasing incidence and severity of anxiety symptoms, decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing patient self-esteem and sense of self-worth.

The clinician recommended patient do the following between sessions: writing down goals to discuss for next session in advance, thinking about observations offered by therapist during the session, journaling about feelings over the course of the week, outreaching to clinician for crisis call as needed, attending next scheduled session, practicing noticing the way particular relationship patterns are positively or negatively reinforced. 

Plan: Clinician and patient plan to meet for next session scheduled for: 8/17/1998. Clinician to remain available ongoing and will follow up as needed. 


	9. Chapter 9

**Summary for the Chapter:**

> content note: self harm (burning)

**Patient Information: Severus S**

**Encounter Information: 8/17/1998 5:00:00 PM**

Clinician: Leticia Rosenberg, LICSW

Boston Institute for Family Therapeutics LLC 

Session Duration: 45min

Type of Session: individual

**PHQ9:** Lack of motivation? 3 Down depressed hopeless? 2 Burden on others? 1 Concentration issues? 0 Energy issues? 3 Sleep issues? 3 Appetite issues? 3 Moving faster or slower than usual? 3 Better off dead / hurting self? 0.  **Total PHQ9: 16**

**GAD7:** Nervous anxious on edge? 2 Unable control worrying? N/A Worrying too much different things? 3 Trouble relaxing? 3 Being so restless hard to sit still? 3 Easily annoyed or irritable? 3 Feeling like something awful’s going to happen? 0  **Total GAD7: 15**

Clinician met with patient for scheduled appointment. Patient endorsed passive suicidal ideation. Patient denied homicidal ideation. Patient denied safety concerns. When asked, pt indicated, "Well, I don't know if it would be considered self harm." Pt looked very uncomfortable and rolled up his sleeve and removed a gauze wrap to reveal a second-degree burn on his under-arm (lh side). SW asked pt for more details about how this burn occurred and pt indicated it was intentional. When SW inquired about the reason for the burn, the pt indicated, "I've been attending tattoo removal sessions for weeks at this point. I admit I lost my temper and figured that outright burning off the skin would be more efficacious and less expensive." . Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: adequate. Patient motivation for change was adequate. Clinician observed the following about the patient during the session: Patient was interested and intellectually curious, Patient was well groomed, Patient seemed lethargic. 

**Focus of Session:** Patient indicated having the following significant events since last session: SW asked pt about his tattoo. He reported it was related to some "regrettable misadventures I had in my youth," and that the constant reminder on his skin "was getting impossible to bear. I've been looking at the damned thing for nearly a quarter century. It doesn't get any easier." Patient identified feeling proud that he had not utilized a razor, "that was my first instinct, was to simply cut through the skin and remove it that way." SW pointed out this other method might very well have led to excessive blood loss and therefore death. Pt just stared at SW pointedly, clearly implying 'that was the point.' SW validated feeling glad patient continues to be in the realm of the living, and pt chuckled bitterly. "That makes one of us." . 

Patient described the following progress in relationships of significance: Patient identified feeling more down this week, "probably because I was getting so little in the way of results from my [tattoo removal] sessions, to be honest." Pt described the tattoo as being "not unlike a Swastika in terms of meaning." Pt reported having joined a gang type group in his youth "because I hated myself, and they offered me the opportunity to have some damn pride, for once in my life. It was a lie, but I believed it long enough to get into trouble." SW pointed out that it sounds like that involvement was what led to the death of the friend / object of his affection. Pt grimly agreed. 

Patient identified need for the following resources from clinician: Pt seemed difficult to read, as per usual, but pt did seem especially relieved to discuss his tattoo situation. "It's been weighing on me for so long." . 

**Clinician completed the following psychometric assessment with patient: PHQ9, GAD7 and patient scored positive for depression and positive for anxiety.**

**Interventions:** Clinician assisted patient in the following: providing encouragement and emotional support to patient, reflecting and summarizing patient concerns, providing emotional validation for patient's experiences, naming feelings, building rapport and engagement in treatment, assessing patient progress towards goals, Encouraging a nonjudgmental, collaborative relationship, Communicating respect for and acceptance of patient and their feelings. Clinician utilized the following interventions: providing mental health psychoeducation, revising current treatment plan, reviewing safety / crisis plan, completing psychometric assessment to assess patient condition severity, asking open-ended questions (Motivational Interviewing skill), supporting self-efficacy and optimism, adjusting to client resistance rather than opposing it directly (Motivational Interviewing skill), observing the connection between thoughts, feelings, and behaviors (cognitive behavioral therapy methods). Patient responded to clinician’s interventions in the following ways: positively. Clinician identified the following barriers to patient progress towards objectives: patient current life circumstances outside of their control, patient lack of emotional strength and resources, patient feelings of inadequacy and low self-esteem, patient despair and depression, patient's stage of change, patient's ongoing challenges with mental health symptoms.

**Treatment Plan:** Throughout session, patient was able to engage in goals set on treatment plan. During the session, clinician and patient reviewed and modified treatment plan. Together, the patient and clinician worked towards the following treatment goal during the session: decreasing incidence and severity of anxiety symptoms, decreasing incidence and severity of depression symptoms, increasing patient engagement in pleasurable activities (behavioral activation), increasing patient awareness of emotions and feelings, continuing patient engagement in treatment with mental health.

**Plan:** Clinician and patient plan to meet for next session scheduled for: 8/24/1998. The clinician recommended patient do the following between sessions: practice using new skill identified in session, thinking about observations offered by therapist during the session, engaging in new idea or activity, attending next scheduled session, practicing noticing somatized emotions in body. Clinician to remain available ongoing and will follow up as needed. 


	10. Chapter 10

**Patient Information: Severus S**

**Encounter Information: 8/24/1998 5:00:00 PM**

Clinician: Leticia Rosenberg, LICSW

Boston Institute for Family Therapeutics LLC 

**Session Duration: 45 minutes**

**Type of Session: Individual psychotherapy**

**PHQ9:** Lack of motivation? 1 Down depressed hopeless? 1 Burden on others? 3 Concentration issues? 0 Energy issues? 2 Sleep issues? 3 Appetite issues? 3 Moving faster or slower than usual? 1 Better off dead / hurting self? 1.  **Total PHQ9: 14**

**GAD7:** Nervous anxious on edge? 3 Unable control worrying? 2 Worrying too much different things? 1 Trouble relaxing? 3 Being so restless hard to sit still? 3 Easily annoyed or irritable? 3 Feeling like something awful’s going to happen? 0  **Total GAD7: 15**

Clinician met with patient for regularly scheduled appointment in office. Patient endorsed active suicidal ideation (fleeting thoughts). Patient denied homicidal ideation. Patient denied safety concerns. denied recent self harm behaviors. Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: adequate. Patient motivation for change was adequate. Clinician observed the following about the patient during the session: Patient was interested and intellectually curious, Patient was casually dressed. 

**Focus of Session:** Patient indicated having the following significant events since last session: Patient seemed in comparably good spirits today. "They are finally noticing that my work has merit," he reflected, seeming to relax into the chair and drape himself over it in a comfortable way previously unobserved by this clinician. "I believe they may hire me permanently." When SW inquired whether this was desirable given pt has found this work environment relatively unpleasant. Pt frowned. "At least I don't have to compromise my morals to work there. I'm not used to... not hating my work environment with every fiber of my being." . 

**Patient described the following progress in relationships of significance:** Given pt's moderately positive outlook this day, SW broached a few points brought up in previous sessions. First, SW mentioned pt's point about "water and me don't mix." Pt seemed horrified at the idea of talking about it, and refused to discuss further. "Please, let's talk about anything else."    
  
SW took this opportunity to bring up pt's previous discussion of his former romantic interest, Lily Evans, specifically how "I was and still remain incredibly jealous of the gifts she was given at birth.” Patient chuckled lowly at this and SW encouraged pt to elaborate on what he noticed in his body. Pt indicated feeling tightness in throat and "sinking feeling" in stomach. "I loved her. I wanted to be her. I don't know what else you want me to say."    
  
SW inquired further what he meant by 'wanted to be her.' "She was beautiful. Clear, pristine skin that looked like snow. Hair the color of a sunset. Parents who loved her. We went over this."    
  
SW inquired how pt previously mentioned "I clean up well." He looked a bit embarrassed, but leaned forward and whispered conspiratorially, "this goes no further, right?" and SW affirmed the confidential nature of clinician's practice while also stipulating limitations.    
  
Pt shook head, saying regarding SW's limitations re: harm of self or others, "that doesn't apply to this." He proceeded to suddenly stand and request use of the restroom; he returned a few minutes later looking slightly (but significantly) different. He had seemingly transformed himself into a feminine version of himself; makeup, a slight change in hairstyle, padding at his chest in the semblance of breasts, and even the way he walked seemed different. SW was visibly aghast, and pt chuckled. "As I said, I clean up well."    
  
SW noted pt's face seemed brighter and happier, a spark of joy in his eye that was new to this SW, and the observation made pt shut down immediately. He stood up, returned to bathroom, and returned looking normal (for him), somber and depressed. "It can never be permanent, unfortunately."    


**Patient identified need for the following resources from clinician:** SW attempted to explore this with pt, and specifically mentioned that there are individuals who come to this SW with similar feelings; SW provided psychoeducation about Gender Identity Disorder.* This seemed to shock pt, who seemed incredulous. SW promised to provide pt with some reading material and encouraged pt to look up "Paris Is Burning" (1990) and the history of Lili Elbe, an early recipient of sex reassignment surgery. Pt seemed intrigued though incredulous. "A trip to the library may be in order," he answered, and seemed thoughtful as he left session. 

**Clinician completed the following psychometric assessment with patient: PHQ9, GAD7 and patient scored positive for depression and positive for anxiety.**

**Interventions:** Clinician assisted patient in the following: providing encouragement and emotional support to patient, reflecting and summarizing patient concerns, providing emotional validation for patient's experiences, naming feelings, educating patient about treatment options, Communicating respect for and acceptance of patient and their feelings, assisting patient in noticing the presence of somatized emotions in their body. Clinician utilized the following interventions: providing mental health psychoeducation, providing empowerment-focused psychoeducation, completing psychometric assessment to assess patient condition severity, asking open-ended questions (Motivational Interviewing skill), supporting self-efficacy and optimism, practicing "notice in body" skill to assist patient in identifying somatized emotions, observing the connection between thoughts, feelings, and behaviors (cognitive behavioral therapy methods), referring patient to resources. Patient responded to clinician’s interventions in the following ways: positively. Clinician identified the following barriers to patient progress towards objectives: patient current life circumstances outside of their control, patient lack of emotional strength and resources, patient feelings of inadequacy and low self-esteem, patient despair and depression, patient's stage of change, patient's lack of education about options, patient's being overwhelmed by unmet concrete needs, patient's challenges with insight into their condition, patient's ongoing challenges with mental health symptoms.

**Treatment Plan:** Throughout session, patient was able to engage in goals set on treatment plan. During the session, clinician and patient decided to continue current treatment plan. Together, the patient and clinician worked towards the following treatment goal during the session: decreasing incidence and severity of anxiety symptoms, decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing independence and ability to self-actualize patient's goals, increasing patient self-esteem and sense of self-worth, increasing patient engagement in pleasurable activities (behavioral activation), increasing patient awareness of emotions and feelings, continuing patient engagement in treatment with mental health, increasing patient coping skills and ability to tolerate distressing circumstances.

**Plan:** Clinician and patient plan to meet for next session scheduled for: 8/31/1998. The clinician recommended patient do the following between sessions: practice using new skill identified in session, thinking about observations offered by therapist during the session, engaging in new idea or activity, reading about new concept, following up with new resource, attending next scheduled session, practicing noticing somatized emotions in body. Clinician to remain available ongoing and will follow up as needed. 

**Notes for the Chapter:**

> Ms. Rosenberg uses the DSM-IV, which uses the diagnostic label Gender Identity Disorder (GID). This term was used until 2013 with the release of the DSM-5, which officially renamed the condition to Gender Dysphoria to remove the stigma inherent in the term 'disorder.' I'm sure there were folks who were using Gender Dysphoria before 2013 but Ms. Rosenberg, while being fairly competent in these matters, has not had her knowledge accordingly updated for the purposes of historical context. I intend to address this in-fiction eventually in a natural way.


	11. Chapter 11

**Patient Information: Severus S**

**Encounter Information: 8/31/1998 5:00:00 PM**

Clinician: Leticia Rosenberg, LICSW

Boston Institute for Family Therapeutics LLC 

**Session Duration: Pt no-showed**

**Type of Session: SW made collateral contact with pt's caseworker**

**PHQ9:** Lack of motivation? N/A Down depressed hopeless? N/A Burden on others? N/A Concentration issues? N/A Energy issues? N/A Sleep issues? N/A Appetite issues? N/A Moving faster or slower than usual? N/A Better off dead / hurting self? N/A. **Total PHQ9: n/a**

**GAD7:** Nervous anxious on edge? N/A Unable control worrying? N/A Worrying too much different things? N/A Trouble relaxing? N/A Being so restless hard to sit still? N/A Easily annoyed or irritable? N/A Feeling like something awful’s going to happen? N/A **Total GAD7:**

Clinician met with patient for SW scheduled appointment for later in week with pt. Patient denied suicidal ideation. Patient denied homicidal ideation. Patient denied safety concerns. Caseworker identified pt has been avoiding meals at shelter.. Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: Pt not present to assess. . Patient motivation for change was Pt not present to assess. . Clinician observed the following about the patient during the session: SW unable to assess. 

**Focus of Session:** Patient indicated having the following significant events since last session: Pt no-showed for this scheduled appt. SW telephoned pt's shelter and spoke with shelter worker. She indicated pt had arrived back to shelter after end of his work shift and simply went straight to bed; he is currently asleep. Worker indicates that pt has been even more withdrawn than usual since around the middle of last week, and while she has not observed any dangerous behavior on his part, she has observed pt avoiding meals. She personally has tried to encourage him to eat dinner (during her shift) and he has refused. He looks visibly more depressed in her opinion, though pt denies having suicidal ideation when she speaks to him. . 

Patient described the following progress in relationships of significance: Pt missed treatment this session. SW scheduled a make-up session with pt's shelter worker for later this week. Worker will reinforce to him that attending treatment is mandatory for his continued enrollment in shelter program and that if pt is unable / unwilling to go to treatment, inpt hospitalization will be considered. . 

Patient identified need for the following resources from clinician: SW encouraged pt's worker to try and encourage pt with positive reasons to attend treatment including being able to express feelings, improve mental health symptoms, and more. Stressed the importance of attending treatment particularly when ambivalent or stressed.. 

**Clinician completed the following psychometric assessment with patient: n/a (did not complete) and patient scored n/a (did not complete) for depression and n/a (did not complete) for anxiety.**

**Interventions:** Clinician assisted patient in the following: attempting to engage pt in treatment through use of collateral contact. Clinician utilized the following interventions: engaging pt in treatment. Patient responded to clinician’s interventions in the following ways: SW unable to assess. Clinician identified the following barriers to patient progress towards objectives: patient current life circumstances outside of their control, patient lack of emotional strength and resources, patient despair and depression, patient's stage of change, patient's challenges with insight into their condition.

**Treatment Plan:** Pt did not attend session. Treatment plan continues as previously stipulated.  
  
 **Plan:** Clinician and patient plan to meet for next session scheduled for: 9/3/1998. The clinician recommended patient do the following between sessions: attending next scheduled session. Clinician to remain available ongoing and will follow up as needed. 


	12. Chapter 12

**Patient Information: Severus S**

**Encounter Information:** **9/3/1998** **7:00:00 PM**

**Clinician: Leticia Rosenberg, LICSW**

**Boston Institute for Family Therapeutics LLC**

  
  


**Session Duration: 45 minutes**

**Type of Session: Individual psychotherapy**

**PHQ9:** Lack of motivation? 3 Down depressed hopeless? 3 Burden on others? 3 Concentration issues? 2 Energy issues? 3 Sleep issues? 3 Appetite issues? 3 Moving faster or slower than usual? 3 Better off dead / hurting self? 3.  **Total PHQ9: 26**

**GAD7:** Nervous anxious on edge? 0 Unable control worrying? 0 Worrying too much different things? 0 Trouble relaxing? 0 Being so restless hard to sit still? 0 Easily annoyed or irritable? 3 Feeling like something awful’s going to happen? 3  **Total GAD7: 6**

Clinician met with patient for regularly scheduled appointment in office. Patient endorsed active suicidal ideation (intent, method, and plan). Patient denied homicidal ideation. Patient denied safety concerns. Pt acknowledges he has been refusing meals and not eating as a means of self harm.. Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: reluctant. Patient motivation for change was reluctant. Clinician observed the following about the patient during the session: Patient was disheveled and poorly groomed, Patient appeared fatigued and exhausted, Patient seemed disengaged and aloof, Patient seemed overwhelmed and stressed, Patient seemed lethargic, Patient was withdrawn and monosybillic. 

**Focus of Session:** Patient indicated having the following significant events since last session: Pt is visibly depressed and exhausted. Pt has missed 2 days of work this week including yesterday and today. Pt is hunched over, staring at the floor, seems disinterested in everything. SW asked if pt followed up with recommendations from prior week; pt denied this. "I went to the city library after our session but it was already closed. It closes at six. What's the point of a library that closes after most people haven't even left work." Pt denies having gone again afterwards. . 

Patient described the following progress in relationships of significance: SW recommended pt go to Central Library at Copley Square because their hours generally are later than other branches. Pt shrugged and seemed disinclined to f/u with this recommendation. SW asked pt what changed since last week, since last week pt was very engaged and seemed very interested in looking up information about gender changes.* Pt shrugged and indicated he "shouldn't have said anything" about it to this clinician. SW asked what pt was feeling and pt insisted "I don't know" to SW's questions. . 

Patient identified need for the following resources from clinician: In response to pt's uncooperativeness, SW talked about how sometimes opening up to a clinician about something so intensely personal can cause feelings of regret and shame. Also about how it can also be like opening up an old wound. SW stressed that opening up old wounds is necessary to perform removal of pain and discomfort, but that the pace of this can be set by the patient in the sessions, and that there's no rush to process anything in therapy. Pt didn't have significant response to this, but seemed less intensely distraught. Mood continued to be low, but pt did say unprompted as he was leaving, "See you on Monday," which SW takes to be a positive sign. . 

**Clinician completed the following psychometric assessment with patient: PHQ9, GAD7 and patient scored positive for depression and negative for anxiety.**

**Interventions:** Clinician assisted patient in the following: providing encouragement and emotional support to patient, reflecting and summarizing patient concerns, educating patient about treatment options, building rapport and engagement in treatment, Encouraging a nonjudgmental, collaborative relationship, Communicating respect for and acceptance of patient and their feelings, identifying underlying feelings beneath 'feeling numb' or disconnected. Clinician utilized the following interventions: providing mental health psychoeducation, completing psychometric assessment to assess patient condition severity, rolling with resistance (Motivational Interviewing skill), asking open-ended questions (Motivational Interviewing skill), adjusting to client resistance rather than opposing it directly (Motivational Interviewing skill), referring patient to resources. Patient responded to clinician’s interventions in the following ways: indifferently. Clinician identified the following barriers to patient progress towards objectives: patient current life circumstances outside of their control, patient lack of emotional strength and resources, patient feelings of inadequacy and low self-esteem, patient despair and depression, patient's stage of change, patient's lack of education about options, patient's being overwhelmed by unmet concrete needs, patient's challenges with insight into their condition.

**Treatment Plan:** Throughout session, patient was disinterested in tx plan to engage in goals set on treatment plan. During the session, clinician and patient decided to continue current treatment plan. Together, the patient and clinician worked towards the following treatment goal during the session: decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing independence and ability to self-actualize patient's goals, increasing patient self-esteem and sense of self-worth, increasing patient understanding of patterns of dysfunction that have evolved over time, increasing patient awareness of emotions and feelings, continuing patient engagement in treatment with mental health, evaluating patient medication management and stability, increasing patient coping skills and ability to tolerate distressing circumstances.

**Plan:** Clinician and patient plan to meet for next session scheduled for: 9/7/1998. The clinician recommended patient do the following between sessions: reviewing safety plan in moments of emotional distress, thinking about observations offered by therapist during the session, following up with new resource, outreaching to clinician for crisis call as needed, attending next scheduled session. Clinician to remain available ongoing and will follow up as needed. 


	13. Chapter 13

**Patient Information: Severus S**

**Encounter Information: 9/7/1998 5:00:00 PM**

**Clinician: Leticia Rosenberg, LICSW**

**Boston Institute for Family Therapeutics LLC**

  
  


**Session Duration: 45 minutes**

**Type of Session: Individual psychotherapy**

**PHQ9:** Lack of motivation? 3 Down depressed hopeless? 3 Burden on others? 3 Concentration issues? 0 Energy issues? 2 Sleep issues? 1 Appetite issues? 3 Moving faster or slower than usual? 3 Better off dead / hurting self? 3. **Total PHQ9: 18**

**GAD7:** Nervous anxious on edge? 3 Unable control worrying? 1 Worrying too much different things? 1 Trouble relaxing? 3 Being so restless hard to sit still? 3 Easily annoyed or irritable? 3 Feeling like something awful’s going to happen? 0 **Total GAD7: 14**

Clinician met with patient for regularly scheduled appointment in office. Patient endorsed passive suicidal ideation. Patient denied homicidal ideation. Patient denied safety concerns. denied recent self harm behaviors. Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: adequate. Patient motivation for change was adequate. Clinician observed the following about the patient during the session: Patient was interested and intellectually curious, Patient was well groomed, Patient seemed skeptical and suspicious, Patient seemed hesitant . 

**Focus of Session:** Patient indicated having the following significant events since last session: Pt seems visibly less depressed than last week. Pt self-reports being frustrated with his weight gain. "I didn't eat for two weeks, and I still put on five pounds. I've put on ten since before I went in the hospital. I feel heavy." SW discussed adjustment to medications and the relationship of depression and weight gain. Pt seemed upset at this. SW probed and pt was reluctant to discuss. "It reminds me of my father." SW inquired more, and pt stated, "I thought we didn't have to talk about anything I didn't want to," referring back to previous session. SW affirmed this and also observed pt, by bringing up the subject, seemed to want to talk about it. Pt denied wanting to, and SW respected pt's boundary.

SW asked what pt did want to talk about. Pt indicated, "Well, perhaps. It's easier than some of the other things you ask me questions about." He elaborated about how his father was a "fat, lazy sod," who "drank away my mother's inheritance and squandered the love he didn't deserve to receive from her." Pt described how food in the household was distributed unevenly: his father worked in the mills [after father and mother had patient, apparently they retired from the stage / vaudeville life] and needed his strength to provide for the family.

That's how his mother justified giving his father a double or triple portion of food while she and pt ate abstemiously, even after the mill closed and pt's father no longer worked hard labor, and even after pt was a teenager. 

SW brought up that pt seemed angry also at his mother for being complicit in dividing the household resources in an unfair manner. "I suppose so," he acknowledged, "though in many ways, I know she was doing it to protect me from being like him." 

SW probed more about whether there are elements of his personality that remind pt of his father. "I'm more like my mother, overall," pt explained, and identified 5 shared traits of his father that he dislikes about himself: pt's fluctuation of mood and experiences of uncontrollable rage; pt's self-described "narcissism" or "thinking I'm better than everyone else"; particular compulsive behaviors such as inability to tolerate certain textures on skin & loud noises (which SW has other opinions about; Note to self talk with Dr Crane about possible asperger's traits?); pt's physical appearance, particularly his nose and skin color; a predisposition to alcoholism. 

Pt also able to identify 5 shared traits of his mother that he does like about himself: "I keep my hair long, like hers - from behind it was hard to tell us apart until she began going grey."; pt's studiousness and focus; pt's appreciation for the "finer things" in life including "music and the arts, though I rarely indulge," social skills and "ability to read people, aside from my father apparently," and talent for craftsmanship, "particularly in esoteric arts." When SW asked for elaboration, pt chuckled to self. "You might describe my mother as a witch."

SW asked pt if he identifies as a warlock, and he agreed. SW reassured pt that SW has experience working with Wiccan patients in the past and that pt could be reassured of the absence of judgment from this clinician. Pt seemed amused by this, privately, but seemed relieved as well. "I may be somewhat different in many respects than your other patients," he mused thoughtfully. SW affirmed that spiritual traditions are complicated and not all branches of the same branch of faith work the same, and pt said cryptically, "Let's go with that explanation." 

Patient described the following progress in relationships of significance: Pt seemed to reopen himself to clinician during this session and by the end he seemed much more at ease and warm towards SW than previously. . 

Patient identified need for the following resources from clinician: SW and pt discussed medication side effects, costs versus benefits of medication, and SW allowed pt to choose direction of conversation. . 

**Clinician completed the following psychometric assessment with patient: PHQ9, GAD7 and patient scored positive for depression and positive for anxiety.**

**Interventions:** Clinician assisted patient in the following: providing encouragement and emotional support to patient, providing emotional validation for patient's experiences, identifying patterns in patient's life, exploring patient strengths and weaknesses, Encouraging a nonjudgmental, collaborative relationship, Communicating respect for and acceptance of patient and their feelings. Clinician utilized the following interventions: completing psychometric assessment to assess patient condition severity, rolling with resistance (Motivational Interviewing skill), asking open-ended questions (Motivational Interviewing skill), supporting self-efficacy and optimism, identifying patterns of positive and negative reinforcement / punishment in patient's life. 

Patient responded to clinician’s interventions in the following ways: positively.

Clinician identified the following barriers to patient progress towards objectives: patient current life circumstances outside of their control, patient lack of emotional strength and resources, patient feelings of inadequacy and low self-esteem, patient despair and depression, patient's stage of change, patient's being overwhelmed by unmet concrete needs, patient's challenges with insight into their condition.

**Treatment Plan:** Throughout session, patient was able to engage in goals set on treatment plan. During the session, clinician and patient decided to continue current treatment plan. Together, the patient and clinician worked towards the following treatment goal during the session: decreasing incidence and severity of anxiety symptoms, decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing independence and ability to self-actualize patient's goals, increasing patient self-esteem and sense of self-worth, increasing patient understanding of patterns of dysfunction that have evolved over time, increasing patient awareness of emotions and feelings, continuing patient engagement in treatment with mental health, evaluating patient medication management and stability.

**Plan:** Clinician and patient plan to meet for next session scheduled for: 9/14/1998. The clinician recommended patient do the following between sessions: reviewing safety plan in moments of emotional distress, thinking about observations offered by therapist during the session, outreaching to clinician for crisis call as needed, attending next scheduled session. Clinician to remain available ongoing and will follow up as needed. 


	14. Chapter 14

**Patient Information: Severus S**

**Encounter Information: 9/14/1998 5:00:00 PM**

**Clinician: Leticia Rosenberg, LICSW**

**Session Duration: 45 minutes**

**Type of Session: Individual psychotherapy**

**PHQ9:** Lack of motivation? 2 Down depressed hopeless? 2 Burden on others? 0 Concentration issues? 0 Energy issues? 3 Sleep issues? 3 Appetite issues? 3 Moving faster or slower than usual? 2 Better off dead / hurting self? 0. **Total PHQ9: 14**

**GAD7:** Nervous anxious on edge? 2 Unable control worrying? 1 Worrying too much different things? 1 Trouble relaxing? 3 Being so restless hard to sit still? 2 Easily annoyed or irritable? 3 Feeling like something awful’s going to happen? 1 **Total GAD7: 13**

Clinician met with patient for regularly scheduled appointment in office. Patient denied suicidal ideation. Patient denied homicidal ideation. Patient denied safety concerns. denied recent self harm behaviors. Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: adequate. Patient motivation for change was adequate. Clinician observed the following about the patient during the session: Patient was interested and intellectually curious, Patient was thoughtful and self-reflective, Patient was well groomed. 

**Focus of Session:** Patient indicated having the following significant events since last session: Patient was significantly more interested in the session than usual. When questioned about this, patient indicated that he felt like things are getting better for him overall. “I can’t remember a time where I didn’t want to be dead, in the very darkest recesses of my mind. Strangely, that feeling is no longer present even there. It is fairly uncomfortable.” Social worker asked patient what made this uncomfortable. “I don’t know what to do if I’m not miserable.” Social worker encouraged patient to consider what life might look like on the other side of depression. Patient just snorted and seemed disbelieving that he would ever get there. “I’ve been depressed for almost 40 years. What makes you think I have a chance?” Social worker validated patient’s concern about it being a challenge to change cognitive patterns that have been set for decades. Social worker also pointed out that this “Being depressed” is probably a Dysfunctional Core belief. Social worker challenged patient to consider times when he might not have been depressed. Even just moments.. 

Patient described the following progress in relationships of significance: Patient identified a few moments in his past where he did not feel 100% depressed. “One time I was with Lily, and we were playing at the old railway museum near Bristol. Her father took us for the weekend and I had never had such fun. We played in the field were they had a Decommissioned old locomotive, Long defunct and not attached to rails that lead anywhere. We climbed all over that thing for an entire afternoon, just yelling and Hollering and being children. I don’t remember exactly what the goal of our game was, I think it was just an imaginative game of pretend. But I remember going to sleep that night thinking that if every day could be like that, it would make up for everything that had gone wrong in my life up to that point.” Patient identified that this memory made him feel sad, and the sadness was localized in his chest and behind his eyes. “I was such a deluded fool.” Social worker contradicted this and pointed out that Severus was around eight years old at that time, and it is reasonable to expect a child to have that kind of hope, especially when this child had suffered so much already so early in his life.  
  
Patient identified two other memories as well. “One time once I was at school, we went to the candy store adjacent to campus. I was poor, but my mother had gifted me the equivalent of perhaps five dollars for the purpose of purchasing civilities on my first “Hogsmeed Weekend”. To me, That amount seemed a luxury too extravagant for words. And so I went into the candy store very confident that I could purchase anything I might want. Well, I was sadly Disillusioned once I saw the prices for a Simple bag of chocolates. I ended up leaving the store and wandering the village until I came across a bookstore. It wasn’t the bookstore that all my classmates went to, with the shiny new covers lined up in the window, but one that was in the shadows, a bit raggedy, a Second hand shop. So I walked in, and I looked around, and I couldn’t believe my eyes. It was so shabby on the outside, but inside everything was laid out so beautifully That I could scarcely imagine a more wonderful place. For the remainder of my school years and teaching years, that was my place of solace and comfort. Agides’ Alley. It reminded me much of my mother: so much effort was put into it, despite how little everyone thought of it. It had a quiet dignity that drew me to it like a moth to a candle.” Social worker identified that patient seemed to feel very poetic about the bookstore. Patient smiled wistfully. “I need to look around for a place like that here in Boston, I suppose.” Patient identified that Being in the shop made all negative feelings melt away off his shoulders.  
  
Patient identified one additional memory that was not entirely depressing to him. “One summer early in my teaching career, I was permitted to wander the grounds as I pleased. It was the hottest day I could remember, and all the other teachers remained inside the Castle. I mean, we called it “the castle” but just because it was an old enormous monstrous building. It may even want to have been a real castle I don’t know. Regardless, I was the only one who was bored enough to venture outside and after a brisk walk I was so overheated that straight away I had to takeoff my jacket. But this was not enough to bring me relief, so I made my way to the lake and stripped completely. I waded into the water. It seemed to sparkle as I looked upon it, The sun catching upon the little rivulets and I allowed myself to sink underneath the water. It was the first time I allowed myself to be completely submerged for years, and it was terrifying and exhilarating at once.”

Social worker validated what effort in must’ve taken to try and get into the water considering how much trauma patient suffered with water in his family of origin. Patient Brushed off this complement with a snarl, stating that he was a “damn fool” for “Being so pathetic as to think of this memory as one where I was happy.”

Social worker gently explored this with patient and patient eventually revealed that he did not believe that his traumatic experiences with water in his past [which he has not elaborated upon, but that social worker suspects involved some sexual abuse in early childhood] were actual trauma. “I just needed to grow up and stop being such a fucking pansy.” Social worker validated patients difficulty with acknowledging past trauma, and patient seemed reluctant to endorse social worker’s view.

Social worker validated that patient might have complicated feelings about this memory, but also encourage patient to allow himself the tiny glimmer of happiness that he remembered in that moment. Social worker encouraged patient not to try and qualify or justify the memory, but just embrace it for what it was. No matter the context. Patient seemed to grumble about this, but he did not argue. . 

Patient identified need for the following resources from clinician: Social worker vocalized feeling very pleased with patient’s progress this session and his willingness to be vulnerable. Social worker encouraged patient and indicated that not every session in therapy has to be this revealing. Not every session in therapy requires this amount of depth and emotional vulnerability. Social worker encouraged patient not to be scared at having “jumped into the water” Of therapy, and encourage patient to just keep showing up, and the work will unfold in its own good time.. 

**Clinician completed the following psychometric assessment with patient: PHQ9, GAD7 and patient scored positive for depression and positive for anxiety.**

**Interventions:** Clinician assisted patient in the following: providing encouragement and emotional support to patient, reflecting and summarizing patient concerns, providing emotional validation for patient's experiences, building rapport and engagement in treatment, encouraging patient to practice creating space for their own opinions, communicating respect for and acceptance of patient and their feelings, identifying underlying feelings beneath 'feeling numb' or disconnected. Clinician utilized the following interventions: providing empowerment-focused psychoeducation, completing psychometric assessment to assess patient condition severity . 

Patient responded to clinician’s interventions in the following ways: positively. Clinician identified the following barriers to patient progress towards objectives: patient current life circumstances outside of their control, patient lack of emotional strength and resources, patient feelings of inadequacy and low self-esteem, patient despair and depression, patient's stage of change, patient's being overwhelmed by unmet concrete needs, patient's challenges with insight into their condition.

**Treatment Plan:** Throughout session, patient was able to engage in goals set on treatment plan. During the session, clinician and patient decided to continue current treatment plan. Together, the patient and clinician worked towards the following treatment goal during the session: decreasing incidence and severity of anxiety symptoms, decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing independence and ability to self-actualize patient's goals, increasing patient self-esteem and sense of self-worth, increasing patient awareness of emotions and feelings, continuing patient engagement in treatment with mental health, evaluating patient medication management and stability, increasing patient coping skills and ability to tolerate distressing circumstances.

**Plan:** Clinician and patient plan to meet for next session scheduled for: 9/21/1998. The clinician recommended patient do the following between sessions: writing down goals to discuss for next session in advance, journaling about feelings over the course of the week, attending next scheduled session, practicing noticing somatized emotions in body. Clinician to remain available ongoing and will follow up as needed. 


	15. Chapter 15

**Patient Information: Severus S**

**Encounter Information: 9/21/1998 5:00:00 PM**

**Clinician: Leticia Rosenberg LICSW**

**Session Duration: 45 minutes**

**Type of Session: Individual psychotherapy**

**PHQ9:** Lack of motivation? 2 Down depressed hopeless? 1 Burden on others? 1 Concentration issues? 2 Energy issues? 2 Sleep issues? 2 Appetite issues? 3 Moving faster or slower than usual? 2 Better off dead / hurting self? 0.  **Total PHQ9: 15**

**GAD7:** Nervous anxious on edge? 1 Unable control worrying? 1 Worrying too much different things? 0 Trouble relaxing? 1 Being so restless hard to sit still? 2 Easily annoyed or irritable? 3 Feeling like something awful’s going to happen? 0  **Total GAD7: 8**

Clinician met with patient for regularly scheduled appointment in office. Patient denied suicidal ideation. Patient denied homicidal ideation. Patient denied safety concerns. denied recent self harm behaviors. Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: adequate. Patient motivation for change was adequate. Clinician observed the following about the patient during the session: Patient was interested and intellectually curious, Patient was thoughtful and self-reflective, Patient was well groomed. 

**Focus of Session:** Patient indicated having the following significant events since last session: "I'm still feeling better. It feels like my mind has been smoldering coals for years, and now the medication has had the effect of drenching the sparks." Pt is visibly more relaxed in therapy room, sitting with legs crossed in front of him, recumbent posture, one arm stretched across the couch and his other hand resting lightly on his work satchel. His hair is tied back in loose ponytail and he looks much healthier, less sallow/jaundiced and with a touch of color in cheeks. He seems perpetually amused, with a hint of smile or smirk noted at moments. Compared to clinician's recollection of how he presented in May, when he sat tightly compact, suspicious, legs together, arms crossed, matted unkempt hair, and obviously malnourished, surly and frowning.    
. 

Patient described the following progress in relationships of significance:    
Pt reports frustration with his body. "I keep gaining weight. I've put on a full stone since before I went to the hospital. I'm not eating much more, I don't think, but I had to get new trousers." SW affirmed that this is a frequent issue with medication for mental health, but also identified that pt is clearly not overweight, and likely is just entering a healthy weight limit for his height. SW provided education about BMI and assisted patient in calculating his; pt is just at the lower end of healthy weight, as SW suspected based on visual assessment. Pt seemed dissatisfied with this, and SW probed more into his discomfort. "I just wish it didn't all go here." He touched his stomach area. SW encouraged pt to articulate where he might prefer the weight to be distributed, and pt seemed disgusted with himself, but stated "I don't know."    
  
SW performed location of self assessment, and asked pt what he thought about working with a clinician who is clearly obese. "It isn't anything to do with you," he stated, "it's just about the way I see myself. There isn't anything wrong with you. In fact, I'd rather look like you than like me." SW probed and asked what pt meant by saying 'like you.' Pt blushed slightly and endorsed that SW is 'extremely pretty' which compliment SW graciously accepted but also encouraged pt to scrutinize his words more carefully, as SW is working with pt in a professional context. SW clarified professional boundaries and identified that while therapy is an intensely personal affair, certain boundaries must be maintained. Pt acknowledged understanding and stated, "as soon as I said that I knew it was too much." SW encouraged pt to not guilt himself too much over this, and acknowledged that testing boundaries in therapy is extremely natural and common, and most patients undergo it at one point or another. Frequently much more crassly, in clinician's experience. Pt seemed reassured by SW's education.    
. 

Patient identified need for the following resources from clinician:    
SW clarified her own intersectional identities as part of location of self exercise: obese, female, heavily tattooed, black, American, social worker, mother. Pt identified that SW's identity "makes me feel comfortable, for the most part," because pt identified feeling like "it looks like you've seen some sh*t," which in pt's mind gives SW more credibility. "Some insipid flighty little thing, insulated by a lifetime's worth of privilege, with a savior complex? I wouldn't have come back. My life has too much grit; it requires a strong constitution. I don't want to have to hold back for the sake of my shrink's feelings."    
  
SW endorsed feeling glad clinician's presentation inspires confidence and probed more about what in particular would have made pt not return if pt was a 'flighty little thing'. "I hate to assume things based on people's looks," pt mused, "but I think you might understand what it's like to not be from the.... right side of the tracks." SW asked why pt assumed this, and pt stated, "you seem like you'd understand why I used to run with the likes of Siouxsie Sioux." Pt told SW about an incident that inspired a punk song by this musician called "Hong Kong Garden" standing up against white supremacists who were taunting the owners/staff of a Chinese take-away restaurant in south-east London.    
  
Pt identified, "I followed the Bromley Contingent from afar. I never had enough money to make it to more than a couple concerts, but one of the sisters of Susan Ballion went to my school. There were enough records to go around, if you were willing to go against the grain and reject convention." Pt snorted as they reflected on this memory. "Not like Lily Evans. She never understood how I could be disapproving of the adults in my life. I always felt a kinship with Siouxsie, though. She had a rotten go of things, same as me." SW reflected upon her own experience as a teenager was in New York City discotheques, and noted appreciation for pt's educating SW on his experiences. Pt seemed appreciative of this. . 

**Clinician completed the following psychometric assessment with patient: PHQ9, GAD7 and patient scored positive for depression and positive for anxiety.**

**Interventions:** Clinician assisted patient in the following: providing encouragement and emotional support to patient, reflecting and summarizing patient concerns, providing emotional validation for patient's experiences, challenging negative self-talk, building rapport and engagement in treatment, assessing patient progress towards goals, encouraging a nonjudgmental, collaborative relationship, education about BMI. Clinician utilized the following interventions: providing empowerment-focused psychoeducation, completing psychometric assessment to assess patient condition severity. . Clinician utilized the following other Therapy interventions:, discussion of historical patterns in patient's life and identifying ways that these patterns play a role in patient's current life circumstances. 

Patient responded to clinician’s interventions in the following ways: positively. Clinician identified the following barriers to patient progress towards objectives: patient feelings of inadequacy and low self-esteem, patient despair and depression, patient’s ongoing challenges with mental health symptoms, patient’s struggles with identity and sense of self, patient’s history of trauma and upsetting personal events, patient’s instability in terms of concrete needs.

**Treatment Plan:** Throughout session, patient was able to engage in goals set on treatment plan. During the session, clinician and patient decided to continue current treatment plan. Together, the patient and clinician worked towards the following treatment goal during the session: decreasing incidence and severity of anxiety symptoms, decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing patient self-esteem and sense of self-worth, increasing patient awareness of emotions and feelings, continuing patient engagement in treatment with mental health, evaluating patient medication management and stability, increasing patient coping skills and ability to tolerate distressing circumstances.

**Plan:** Clinician and patient plan to meet for next session scheduled for: 9/28/1998. The clinician recommended patient do the following between sessions: reviewing safety plan in moments of emotional distress, thinking about observations offered by therapist during the session, outreaching to clinician for crisis call as needed, attending next scheduled session. Clinician to remain available ongoing and will follow up as needed. 


	16. Chapter 16

**Patient Information: Severus S**

**Encounter Information: 9/28/2020 5:00:00 PM**

**Clinician: Leticia Rosenberg, LICSW**

**Session Duration: 45 minutes**

**Type of Session: Individual psychotherapy**

**PHQ9:** Lack of motivation? 0 Down depressed hopeless? 1 Burden on others? 0 Concentration issues? 0 Energy issues? 1 Sleep issues? 1 Appetite issues? 3 Moving faster or slower than usual? 0 Better off dead / hurting self? 0.  **Total PHQ9: 6**

**GAD7:** Nervous anxious on edge? 0 Unable control worrying? 0 Worrying too much different things? 0 Trouble relaxing? 1 Being so restless hard to sit still? 1 Easily annoyed or irritable? 2 Feeling like something awful’s going to happen? 0  **Total GAD7: 4**

Clinician met with patient for regularly scheduled appointment in office. Patient denied suicidal ideation. Patient denied homicidal ideation. Patient denied safety concerns. denied recent self harm behaviors. Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: enthusiastic. Patient motivation for change was enthusiastic. Clinician observed the following about the patient during the session: Patient seemed upbeat and engaged, Patient was interested and intellectually curious, Patient was thoughtful and self-reflective. 

**Focus of Session:** Patient indicated having the following significant events since last session: SW walked in with determination and confidence. Pt seemed excited to attend therapy today, and SW noted this. Pt denied knowing this, but he seemed to be fibbing a bit; there was a glint in his eye and a smirk on his face as he shrugged off the observation. Overall pt appears quite well, energetic, sprightly, and slightly less guarded than usual.. 

Patient described the following progress in relationships of significance:    
Pt identified that he has attended a support group for men who have sex with men at the local gay/lesbian community center this past week. SW indicated surprise, as pt previously indicated he was heterosexual (as far as SW recalls). Pt indicated, "I have been known to dabble on both sides," but did not elaborate and refused to explain further. He did endorse that he plans to return to the group again, though he did not share anything in the group. "It's not entirely my crowd, but they are better men than I." Pt endorsed having learned, "not all of them had sh*tty fathers. Some of them did, but a non-zero number of them had decent folks growing up. This was a revelation."    
  
SW asked pt what it felt like to have communicated with others who experience non-normative sexuality. Pt grinned bitterly and endorsed, "at least one of them also had an unpleasant experience with their father." SW probed further about patient's experiences with sexuality, specifically when pt first identified as something other than straight. "I didn't think of it as an identity until I started... um, until I came to Boston." He frowned. "It's not usual, where I come from, to make a great to-do over one's sexual activities. Advertising it was seen to be in grotesquely bad taste, but anything was accepted to some extent. At least among the upper echelons of society in which I generally traveled. I honestly got more grief about it from other poor people. Ironically, like my father."    
  
SW probed further about pt's experiences in the "upper echelons of society" since this seems so incongruous with pt's presentation and his current homelessness. "Obviously they don't know I'm alive," he huffed, seeming to be somewhat offended. "Otherwise I'm sure they'd be pounding down my door, demanding all kinds of things from me." When prompted, pt continued, "They always were asking things from me. Severus, would you make my wife some anti-wrinkle serum and put it in a bottle labelled sunscreen? Severus, would you accompany this shipment of black-market animal hides from the vendor to our secret storage facility? Severus, would you serve as a bodyguard for me while I attend the World Cup? Severus, would you make sure my poor ignorant sap of a son doesn't murder the headmaster this year?" Patient sighed and shook his head, then looked at SW. "You must think I'm a nutter," he sighed, with a moment of clarity dawning on his face. "What I'm telling you sounds patently delusional, to your ears, I'm sure. Believe what you want to, I suppose. Just don't give me antipsychotics." . 

Patient identified need for the following resources from clinician: SW and pt discussed pt's experience with medication, and if pt is still concerned about the weight gain side effects. Pt shrugged. "I've done some reading. It isn't as bad as it could be, I suppose. I've been doing some reading on these medications I'm on, and I suppose if the difference is being fat or dead, I guess the rational choice is to choose to be...not dead." . 

**Clinician completed the following psychometric assessment with patient: PHQ9, GAD7 and patient scored positive for depression and negative for anxiety.**

**Interventions:** Clinician assisted patient in the following: providing emotional validation for patient's experiences, enhancing patient self-respect and positive regard, educating patient about treatment options, building rapport and engagement in treatment, assessing patient progress towards goals, encouraging patient to practice creating space for their own opinions, evaluating patient's values and patient's engagement in meaningful activities, encouraging a nonjudgmental, collaborative relationship. Clinician utilized the following interventions: providing mental health psychoeducation, completing psychometric assessment to assess patient condition severity. . . . . . . . 

Patient responded to clinician’s interventions in the following ways: positively. Clinician identified the following barriers to patient progress towards objectives: patient despair and depression, patient’s ongoing challenges with mental health symptoms, patient’s inflexible/rigid mindset, patient’s struggles with identity and sense of self, patient’s history of trauma and upsetting personal events, patient’s instability in terms of concrete needs, patient’s challenges to adjust to medication / side effects.

**Treatment Plan:** Throughout session, patient was able to engage in goals set on treatment plan. During the session, clinician and patient decided to continue current treatment plan. Together, the patient and clinician worked towards the following treatment goal during the session: decreasing incidence and severity of anxiety symptoms, decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing independence and ability to self-actualize patient's goals, increasing patient self-esteem and sense of self-worth, increasing patient awareness of emotions and feelings.

**Plan:** Clinician and patient plan to meet for next session scheduled for: 10/5/1998. The clinician recommended patient do the following between sessions: practice using new skill identified in session, thinking about observations offered by therapist during the session, outreaching to clinician for crisis call as needed, attending next scheduled session. Clinician to remain available ongoing and will follow up as needed. 


	17. 10/5/1998

**Patient Information: Severus S**

**Encounter Information: 10/5/1998 5:00:00 PM**

**Clinician: Leticia Rosenberg LICSW**

**Session Duration: 45 minutes**

**Type of Session: Individual psychotherapy**

**PHQ9:** Lack of motivation? 3 Down depressed hopeless? 3 Burden on others? 1 Concentration issues? 2 Energy issues? 3 Sleep issues? 3 Appetite issues? 3 Moving faster or slower than usual? 3 Better off dead / hurting self? 1.  **Total PHQ9: 22**

**GAD7:** Nervous anxious on edge? 3 Unable control worrying? 3 Worrying too much different things? 2 Trouble relaxing? 3 Being so restless hard to sit still? 3 Easily annoyed or irritable? 3 Feeling like something awful’s going to happen? 0  **Total GAD7: 17**

Clinician met with patient for regularly scheduled appointment in office. Patient endorsed passive suicidal ideation. Patient denied homicidal ideation. Patient denied safety concerns. denied recent self harm behaviors. Patient was oriented to time, place, person, and situation. Patient engagement and rapport with clinician was: adequate. Patient motivation for change was reluctant. Clinician observed the following about the patient during the session: Patient was thoughtful and self-reflective, Patient appeared fatigued and exhausted, Patient seemed nervous and preoccupied, Patient seemed skeptical and suspicious, Patient was well groomed. 

**Focus of Session:** Patient indicated having the following significant events since last session: Pt was visibly more down and distressed than previous week. "I ran out of medication. There was an issue with my insurance. I didn't have it from the 1st to today. It's all sorted out now, I had to pay money to the department of social services for some reason. But at this point it's resolved." Pt seemed more irritable, and when SW asked if pt felt like his mood was negatively impacted by the medication shortage, pt rolled his eyes and snapped, 'Obviously.' SW acknowledged pt's feelings of this being obvious cause and effect and stated that it is necessary sometimes to ask clarifying questions to confirm understanding. Pt seemed confused by this. "If you understand, you understand. If you don't, you ask. I don't understand the necessity to ask if you understand." SW tried to educate patient that sometimes one might think one understands, but not actually understand. Pt wrinkled his nose at SW and seemed rigid in his belief otherwise. "It sounds like a puffy thing, to me," he commented under his breath, but refused to elaborate as to what this might mean. . 

Patient described the following progress in relationships of significance: SW and pt seemed to be experiencing a day where both were out of synch with each other, at first. Pt kept accusing SW of not listening when SW was asking clarifying questions, and pt began accusing SW of being a "sh*tty shrink," and stated, "I don't even know why I had any hope for this," (referring to therapy). SW suggested that the two of them 'reset' the session and try again; pt stomped out of the room but, after a few moments to self-soothe, he returned to the session with a completely neutral expression and flat affect. His eyes even seemed darker than when he was in the room before. Pt was much more even-keeled in temper, but when SW inquired about how 'last session' went, pt just shrugged and said he didn't know what happened. "I just spouted off." . 

Patient identified need for the following resources from clinician: While he did not apologize, he seemed to acknowledge his blaming behavior was inappropriate and carried some possibility of harm to clinician. "You do listen," he said at end of session, "just there's some things you miss." SW inquired what SW has missed, and pt just shrugged and said cryptically, "I trust you'll figure it out." SW will explore this further in next session. Pt seems to be reactive to something; SW will review notes from previous session and try and identify anything SW missed. This pt seems to struggle a great deal with attachment to this clinician; a few sessions ago pt and clinician rapport was very strong, but this week something seems to have shifted and pt seems to be withdrawing. SW will continue to discuss with pt and explore in clinical supervision with Dr. Crane this week. . 

**Clinician completed the following psychometric assessment with patient: PHQ9, GAD7 and patient scored positive for depression and positive for anxiety.**

**Interventions:** Clinician assisted patient in the following: providing encouragement and emotional support to patient, challenging negative self-talk, assessing patient progress towards goals, encouraging a nonjudgmental, collaborative relationship, communicating respect for and acceptance of patient and their feelings, encouraging patient to dismiss self-reproach and guilt/shame responses, identifying underlying feelings beneath 'feeling numb' or disconnected, assisting patient in identifying precipitating factors that made them emotionally vulnerable to a negative experience. Clinician utilized the following interventions: providing mental health psychoeducation, providing empowerment-focused psychoeducation, completing psychometric assessment to assess patient condition severity, reviewing safety / crisis plan. . . . . . . . 

Patient responded to clinician’s interventions in the following ways: indifferently. Clinician identified the following barriers to patient progress towards objectives: patient feelings of inadequacy and low self-esteem, patient despair and depression, patient’s ongoing challenges with mental health symptoms, patient’s inflexible/rigid mindset, patient’s struggles with identity and sense of self, patient’s history of trauma and upsetting personal events, patient’s instability in terms of concrete needs, patient’s medical concerns, patient’s challenges to adjust to medication / side effects.

**Treatment Plan:** Throughout session, patient was able to engage in goals set on treatment plan. During the session, clinician and patient decided to continue current treatment plan. Together, the patient and clinician worked towards the following treatment goal during the session: decreasing incidence and severity of anxiety symptoms, decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing independence and ability to self-actualize patient's goals, increasing patient self-esteem and sense of self-worth, increasing patient awareness of emotions and feelings, continuing patient engagement in treatment with mental health, evaluating patient medication management and stability, increasing patient coping skills and ability to tolerate distressing circumstances.

**Plan:** Clinician and patient plan to meet for next session scheduled for: 10/12/1998. The clinician recommended patient do the following between sessions: thinking about observations offered by therapist during the session, outreaching to clinician for crisis call as needed, attending next scheduled session. Clinician to remain available ongoing and will follow up as needed. 


	18. 10.12.1998

**Patient Information: Severus S**

**Encounter Information: 10/12/1998 5:00:00 PM**

**Clinician: Leticia Rosenberg LICSW**

**Session Duration: 45 minutes**

**Type of Session: Individual psychotherapy**

**Follow Up from Previous Session:** SW reviewed notes from previous sessions and discussed with Dr. Crane. SW brought this up with pt and discussed pt's expectations related to treatment. Specifically pt identified at previous session his disappointment in SW; "there's some things you miss." 

SW reflected on how pt had mentioned his father twice in 9/28 session, and SW failed to probe deeper with pt. Pt nodded curtly and seemed resigned, but somewhat appreciative of SW's observation. "That's right," he said. 

SW offered to open the conversation to discuss this, and pt shrugged. "I'm not interested in doing so now." SW pointed out that it must have been deeply invalidating for the pt, when SW missed such an overture (subtle though it might have been), particularly as the pt was tentatively bringing up something related to a deep trauma that pt previously was unable to discuss. Pt didn't respond out loud to this, but seemed relieved and seemed to sniffle a bit, though SW did not observe pt have any overt reaction. 

SW validated pt's bravery at saying something about it and challenging SW, and acknowledged that the therapeutic rapport is still new, and that challenging SW must have been incredibly scary for pt to risk fracturing the relationship with SW. Pt shrugged and seemed ill at ease, and asked, 'is it brave for a drowning man to clutch onto a life preserver?' SW acknowledged that while pt feels desperate, he also seems to have enough hope to keep holding on. Pt chuckled lowly and avoided SW's gaze, suggesting to SW the pt's continued latent suicidal ideation.

 **Focus of Today’s Session (what we talked about):** Pt and SW discussed the therapeutic relationship in detail. Pt endorsed feeling hopeless about treatment at previous session and SW acknowledged that if pt feels this way, there are options. SW encouraged pt to consider the following options: a) termination with this clinician and transfer to another clinician, b) work through the discomfort with this clinician and identify ways to improve treatment's effectiveness, c) discontinue with therapy entirely, d) pivot modality of treatment. SW and pt discussed the areas in which SW ha **s** training and what might be compatible with pt's treatment needs. 

Pt identified he would be interested in continuing to work with this clinician and potentially pivoting modalities as well in time. SW has identified that pt would likely benefit from EMD methods, processing memories that have remained in pt's unconscious for decades in order to reduce the pain that these memories cause pt. Pt tentatively agreed to this with the caveat that he is "not yet ready to open up many things," but he would consider exploring the method with this clinician. SW validated that the goal of treatment is to go at pt's own pace, and SW indicated not wanting to pressure pt to open up more than he desires. SW reflected back on 9/28 session and the way SW did not delve deeper into pt's bringing up his father, this was likely in the moment a calculation based on SW's understanding of pt's sensitivity on the topic. 

This statement did seem to make pt visibly more depressed and self-reproachful. "Of course, that sounds about right," he murmured, looking down at the floor, "I know I am talking out of my arse and my mouth at once. It must be impossible working with me." SW offered pt the opportunity to discuss this further; pt elaborated, "I say I don't want to be pressured, and then I tell you off for not pressuring me. Entirely mad, I know. What a load of bollocks." 

SW observed pt seem to break down visibly, crumpling into himself, but then he straightened up again with a sudden alertness. "We didn't do our checklist," he observed, and SW acknowledged having forgotten since SW was concerned about pt's feelings about the last session. Unfortunately SW did not have time to review the PHQ9 and GAD7 this session as already session had gone over time and SW's next pt had already knocked twice. Pt endorsed understanding and endorsed safety. SW will f/u with pt next session.

 **Most Helpful Take-Away:** Pt endorsed "I appreciate that you are in a uniquely difficult position, working with me. I'm not simple and easy, I'm sure, and I appreciate your kindness. I'm... not used to it, or depending on others." SW validated that this is part of the healing power of the therapeutic relationship, and endorsed feeling glad that pt feels SW's unconditional positive regard. 

**Recommendations/Skill(s) to Try:** SW encouraged pt to identify what would make it feel like therapy is working for him. .

**Treatment Goal(s) Addressed This Session:** decreasing incidence and severity of anxiety symptoms, decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing independence and ability to self-actualize patient's goals, increasing patient self-esteem and sense of self-worth, increasing patient engagement in pleasurable activities (behavioral activation), increasing patient awareness of emotions and feelings, continuing patient engagement in treatment with mental health, evaluating patient medication management and stability, increasing patient coping skills and ability to tolerate distressing circumstances.

 **Objectives (steps to get to goals):** attending regularly scheduled therapy appointment 

**Methods Used:** Motivational Interviewing, Interpersonal

 **Next Session:** 10/19/1998


	19. 10.19.1998

**Summary for the Chapter:**

> content note: implied sexual abuse / quid pro quo stuff with Lucius from when sev was 13, noblesse oblige

**Patient Information: Severus S**

**Encounter Information: 10/19/1998 5:00:00 PM**

**Clinician: Leticia Rosenberg LICSW**

**Session Duration: 45 minutes**

**Type of Session: Individual psychotherapy**

PHQ9: **27.3** GAD7: **18**

**Follow Up from Previous Session:** Patient came in and rattled off elements from the PHQ9 and GAD7 (apparently pt memorized most of the questions and possible responses). Despite acuity of symptoms, pt's affect was almost upbeat, smirking, a bit proud of self. (Not congruent with stated mood). 

**Focus of Today’s Session (what we talked about):** SW asked what pt was feeling/thinking with rattling off the assessments, and pointed out that pt seems to not be quite as badly off as stating.  
  
Pt shrugged, and seemed a little bit deflated. "I just want to do this properly so I can get done and over with it," pt stated, "is that not correct to do?" Discussed with pt how therapy is a journey and not something that can be rushed by doing things 'correctly.' Pt acknowledged (when prompted by SW) that he is frequently concerned with doing things 'correctly' sometimes to the exclusion of doing it safely. Pt admitted to being highly critical of self, and holding self to an unreasonable standard.  
  
SW and pt talked about pt's feelings of low self-esteem and SW provided psychoeducation as to how pt's mental health condition is not reflective of pt's worth as a human being. Pt identifies having been an exemplary student in school (which is quite obvious from pt's intelligence and fastidiousness that he was really gifted in academics, with a tremendous memory as demonstrated today at beginning of session). Reflected on how despite pt's academic abilities, pt was never able to be 'good enough' for himself.  
  
Pt and SW were able to connect low self-esteem to pt's feelings of inferiority in school. Pt talked about being of ignoble birth compared to more privileged peers at pt's elite educational institution. Pt also identified the ways that pt also didn't fit in with other individuals who were also underprivileged. Pt identified feeling very alone during his middle to high school years.  
  
Part of the reason pt did not fit in with underprivileged peers was because of pt's self-described 'ambition' and passionate pursuit of improved status. Pt purportedly attempted so hard to fit in with the more privileged peers; pt reports having sacrificed self-respect deeply by participating in sexual favors for social status and protection.  
  
Pt described the transactionality of pt's school-age sexual relationships with a bare-bones, functional type of approach. However he seemed to have a unique spark of inspiration / animatedness in features while discussing experiences with his former sexual partner, Lucius. "He saw something in me that I couldn't see in myself, I suppose," pt identified.   
  
Pt identified having obtained protection from Lucius - "It was like being a knight's page, is the best way I can describe our relationship. It meant that I was basically his property from the moment he and I began spending time together." Pt clarified the relationship started off as being more service-oriented and non-sexual, but on pt's 13th birthday, during pt's second year at school, Lucius initiated 'seduction lessons' with pt.  
  
SW pointed out that the significant age difference and suggested that Lucius behaved in a predatory manner; pt seemed nonplussed by this. "It was not uncommon in our school," pt said, "and generally being given this kind of opportunity was perceived to be a privilege." Pt also identified that "Our classmates wouldn't touch me for fear of him. It made me feel more invulnerable than I really was, and I was willing to do anything for him in exchange for that power."  
  
Pt seems unaware at the level of manipulation and power dynamics that must have been involved in that relationship; Lucius was almost 18 when pt turned 13, an age difference of five years.  
  
Pt seemed disinterested in discussing this. "It didn't matter, Ms. Rosenberg. All this would have been a mere footnote in my life had it ended there. But I somehow tweaked James Potter's nose the wrong way and I got into heaps of trouble with him. That's what I want to talk more about."  
  
The rage seemed evident in pt's face as pt discussed this. " Lucius' family power could only go so far as to impressing a spoiled brat who had never been refused a thing in his life. I think Potter took it as a personal affront that I should be under Lucius' protection, and despite his eventual stance against the war, I think he was just as prejudiced against my blood status as the rest of them. I think he was even more prejudiced against me than Lucius was, actually. Lucius didn't give a fuck about my affection for Lily Evans. Potter took my attentions towards her personally - the way he talked about her with his mates, she was just a prize racehorse, and someone of my ignoble birth couldn't deserve her."  
  
Pt laughed a bit, clearly bitter. "What a misogynstic prick. Her blood status didn't matter one bit because he didn't see her as a person. Noblesse oblige, I suppose."  
  
SW reflected that it must have been devastating to hear these kinds of words about pt's beloved, and SW asked whatever happened to Lily.  
  
This caused the pt to sit straight up and stare at SW with incredulous eyes. "Is it possible I never mentioned this?" he asked, apparently to self, and then he passed his tongue over his lips. Pt whispered with intense seriousness, "She married the damned fool. And then I killed her."   
  
At this point, session had already been overtime for several minutes and SW attempted to schedule a follow-up session for the next day. Pt seemed indifferent and deflated, and seemed to have turned inwards.  
  
"I'll just wait until next week."  
  
Pt was able to contract for safety and denied active suicidal ideation.

 **Most Helpful Take-Away:** "I suppose telling you what happened with her. I'm surprised I haven't before. I should think that's somewhat of an important detail." 

**Recommendations/Skill(s) to Try:** SW and pt will discuss what would make it feel like therapy is working for him. (We didn't get to it today. 

**Treatment Goal(s) Addressed This Session:** decreasing incidence and severity of anxiety symptoms, decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing independence and ability to self-actualize patient's goals, increasing patient self-esteem and sense of self-worth, increasing patient engagement in pleasurable activities (behavioral activation), increasing patient awareness of emotions and feelings, continuing patient engagement in treatment with mental health, evaluating patient medication management and stability, increasing patient coping skills and ability to tolerate distressing circumstances.

**Objectives (steps to get to goals):** attending regularly scheduled therapy appointment 

**Methods Used:** Motivational Interviewing, Interpersonal

**Next Session:** 10/26/1998


	20. 10.26.98

Patient Information: Severus S 

Encounter Information: 10/26/1998 5:00:00 PM 

Clinician: Leticia Rosenberg LICSW

Session Duration: 45 minutes

Type of Session: Individual psychotherapy

PHQ9: 16.2 GAD7: 17

Follow Up from Previous Session:

Pt showed up for session; he seemed in more constrained spirits than last session, but there was an apparent look of hunger for approval in his eyes. He answered PHQ9 and GAD7 without theatrics or exaggeration, quite neutral in tone. SW was on tenterhooks after patient’s significant disclosure from last week. 

Focus of Today’s Session (what we talked about): SW addressed pt’s significant disclosure from last week related to Lily Evans. Pt seemed to be expecting this question and he nursed it for several long moments. “I was in a melodramatic mood,” pt stated “I know it was not my hand itself that did the deed. But the Blame does lay at my door.”

  
He proceeded to explain that he inadvertently made Lily Evans a target of the hate group he joined as a teenager, and the leader sought Lily’s son out specifically to make an example of him.   
  
Pt purportedly turned on the hate group at that point and became a double agent in the hate group on behalf of a power broker (Al) who promised to protect Lily and her family. Due to a betrayal of one of James’ “idiot friends,” the family’s safety was compromised and ambushed in the middle of the night on Halloween 1981. Lily ended up sacrificing herself to save her son.   
  
“She was never Tom’s intended target, but her purity of heart led her to put herself between a weapon and her infant. I’ve been trying to live up to her martyrdom ever since.”   
  
Pt states after the attack, the hate group got disrupted and disbanded for awhile. In the meantime, pt developed educational goals and teaching career. Ten years later Lily’s son Harry started attending the same school where pt taught, and pt reports having saved “the ungrateful little prick’s life at least a dozen times over.”   
  
Pt explained he worked very hard to try and successfully describe pt’s story in a concise and understandable way, and he had been rehearsing it in his mind ever since leaving session last week. (Note: some repetitive behaviors to examine further).   
  
SW provided validation for pt’s story and indicated how much progress pt has made in trusting SW in less than a year. Pt seemed both gratified and mortified and seemed reluctant to talk much about his relationship with the clinician, though he did say, “you have proven to remain trustworthy so far. It stands to reason I would begin to share more with you. I suppose having withheld things Ike this have done a disservice to your ability to help me.”   
  
Pt seemed frustrated that SW could not offer an immediate fix to pt’s distress. SW indicated that pt has made significant progress but that pt is still at the very beginning of the healing journey. Pt seemed taken aback by this and seemed weakened at the prospect that this work will continue to take years.   
  
SW picked up on pt mentioning that pt’s experience with the holiday of Halloween is significant. He nodded. “It isn’t a day I look at with glee,” he affirmed, and added, “a hundred and one awful things have happened on or around Halloween since I was a child. It almost feels like a curse.” He chuckled ruefully and seemed to believe the idea more deeply than he was willing to acknowledge.   
  
SW inquired about pt’s sleep - asked if pt has nightmares or similar. Pt nodded but refused to elaborate. “We are at time, and I do not wish to make your next patient resent me too much.” SW offered pt opportunity to meet again later in the week to provide support to pt surrounding Halloween and pt seemed extremely grateful and agreed to it.   
  
SW and patient briefly discussed what pt needs to objectively feel in order to consider treatment a success. “I just need to have less of these... pernicious thoughts chewing at my brain.”   
  
Sw provided psycho education to pt related to this sounding like automatic thoughts. SW encouraged pt to remember and take to heart the concept that “feelings are not facts.” 

Most Helpful Take-Away: 

Pt acknowledged “I have always taken great pride in my ability to control my thoughts - but since May when everything happened, I feel constantly flooded. The dam is broken. The thoughts consume me like they haven’t since I was a pathetic teenager. I want to try and regain control over my mind.” 

Treatment Goal(s) Addressed This Session: decreasing incidence and severity of anxiety symptoms, decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing independence and ability to self-actualize patient's goals, increasing patient self-esteem and sense of self-worth, increasing patient engagement in pleasurable activities (behavioral activation), increasing patient awareness of emotions and feelings, continuing patient engagement in treatment with mental health, evaluating patient medication management and stability, increasing patient coping skills and ability to tolerate distressing circumstances.

Objectives (steps to get to goals): attending regularly scheduled therapy appointment 

Methods Used: Motivational Interviewing, Interpersonal

Next Session: 10/30/1998


	21. 10.30.98

Patient Information: Severus S 

Encounter Information: 10/30/1998 11:00am 

Clinician: Leticia Rosenberg LICSW

Session Duration: 60 minutes

Type of Session: Individual psychotherapy

PHQ9: not completed GAD7: not completed

Follow Up from Previous Session:

Pt came into session looking extremely down. SW screened for SI; pt endorsed active automatic thoughts but denied having intent. Pt endorsed having had fleeting thoughts of running into traffic on the way home from work yesterday. Pt called out sick today from work in order to attend this appointment. Pt agreed that if his intent changes to active, he will go to identified emergency room nearest the shelter where he currently resides. 

**Focus of Today’s Session (what we talked about):** “I hate how she still preoccupies so much of my mind. I find my mind wandering to memories I haven’t revisited for years. Any time my mind is not wholly occupied, I end up drifting to the very far past. Sometimes I feel as though it’s been only a minute but it has been several.”   
  
Pt identifies that since May when he first arrived into Boston, pt has been unable to compartmentalize his trauma. Pt also identified having started to have what sound to be flashbacks around this time. SW provided psycho education related to trauma activation - it sounds as though pt had severely compartmentalized his psyche and fragmented as a trauma response. The pt is now attempting to reconcile the fragmented psyche and re integrate the fragments into a whole.   
  
SW identified a number of pt’s fragments that are in various stages of repair. Particularly SW observed several pieces that are critical to pt’s psychic construction: his low self-esteem, his self criticism and perfectionist behaviors, his admiration and adoration of the divine personified in the form of Lily Evans, the power and class imbalances pt constantly struggled to compromise between, the sexual experiences pt has had where pt was used for his body, his being constantly in the middle and torn between two manipulators, and his high levels of achievement in professional and military spheres.   
  
Pt seemed to appreciate this insight and identifies it seems to accurately represent the challenges he is having in his mind. “And they say Muggles can’t understand us,” he uttered under his breath. He seemed deeply shaken by SW’s synthesis. He sank his head down into his hands for the better part of a minute and SW prompted patient to practice noticing what he felt in his body.   
  
He acknowledged these when prompted : heart racing, breath pressured, racing thoughts, stomach twisting, muscles in jaw clenching, leg muscles tending, a desire to curl up into a ball.   
  
SW requested pt think back to a previous time he felt like this and patient identified feeling like this when Lily died. Pt identified this memory as being extremely painful, 10/10 subjective units of distress. Pt was with prompting able to flip back to an earlier time where he felt similarly: when he was humiliated in front of the whole school by his tormenter who strung him up in a tree upside down, revealing pt’s undergarments. SW asked pt about earlier memories but pt seemed to visibly shut down. He stared straight ahead and clearly dissociated. SW had to grasp his shoulder and shake him gently to get him out of the dissociated state.   
  
Pt lost time and sense of self during this lapse and it was as radical as shaking an Etch a Sketch, pardon the colloquialism. His face was blank and neutral and he seemed ignorant to the conversation that has been happening prior to the lapse. “I remember we were discussing compartmentalization.”   
  
SW reflected on SW’s observations during the episode of dissociation and how it was preceded by intense panic and the suggestion of re integrating different fragmented pieces of pt. He looked sick at the idea and identified feeling like “there are too many fragments, and so many of them have been ground underfoot and kicked asunder. I find it difficult to believe in the possibility of repair. There’s too much missing and gone.”   
  
SW invited pt to look at some kintsugi pottery that SW keeps in office. Pt was impressed and had not seen before. SW specifically explained the point of the art is a metaphor - to illustrate that it is possible to create something even more beautiful out of broken pieces of a fragmented soul. Pt seemed thoughtful and moved at this. “It’s a pretty thought,” he said and chuckled bitterly. “Naive perhaps, but pretty.” He swung around and asked SW directly, “so you think I can be repaired and be more beautiful than how I was born?”   
  
This seemed to be a loaded question with a deeper meaning; SW wonders if this may be a moment pt was thinking about his challenges with gender identity. SW did provide reassurance and expressed optimism and hope for patient, reflecting on successes made thus far and pointed out that pt started off sessions with this clinician contemplating suicide as an alternative. SW pointed out pt seems to have increased hope as pt still is attending treatment with SW and hasn’t killed himself yet. Pt identified “I suppose so,” and then observed the time.  
  
SW and pt reviewed pt’s safety plan and modified it to ensure pt has at least a few options for his day tomorrow. Pt plans to go to library, then attend a seminar at the LGBt center, and then go and get a good dinner at a local vegetarian restaurant before retiring to the shelter in advance of Halloween trick or treating festivities taking place. Pt says he will take a Benadryl and go to bed early listening to a library audio book on tape he has been reading to go to sleep for the past week (a culinary travelogue)

**Most Helpful Take-Away:** “I appreciate your taking the time to make space for me in your schedule. I hope that the plan we have made will be of help.”

Treatment Goal(s) Addressed This Session: decreasing incidence and severity of anxiety symptoms, decreasing incidence and severity of depression symptoms, decreasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing independence and ability to self-actualize patient's goals, increasing patient self-esteem and sense of self-worth, increasing patient engagement in pleasurable activities (behavioral activation), increasing patient awareness of emotions and feelings, continuing patient engagement in treatment with mental health, evaluating patient medication management and stability, increasing patient coping skills and ability to tolerate distressing circumstances.

Objectives (steps to get to goals): attending regularly scheduled therapy appointment 

Methods Used: Motivational Interviewing, Interpersonal

Next Session: 11/2/1998


	22. 11.1.1998

**Summary for the Chapter:**

> content: more suicidal stuff sorry

Patient Information: Severus S 

Encounter Information: n/a 

Clinician: Leticia Rosenberg LICSW

Session Duration: 15 minutes

Type of Session: phone session

PHQ9: not completed GAD7: not completed

SW received call from pt at 1:03am on 11/1/1998. Pt was in the emergency room at Boston Convalescence for active suicidal ideation. Pt is intoxicated and presents with slurred speech. "I followed the plan. It didn't work. Nothing works. The curse isn't...isn't broken. The only fucking reason I'm here is out of respect for you as a professional. I don't want my death on your conscience. You've done everything you could for me. I'm the piece of utter shite that can't get his fucking life together." 

SW provided validation and provided positive reinforcement for following the plan and also for the bravery of outreaching to clinician. SW provided encouragement to pt and encouraged him to remember that there are peaks and valleys in the course of treatment, and pt's feelings of lack of progress are informed by pt's depression. 

"I wanted to tell you something last session, but I was a coward," he said, ignoring SW's statements. "I never want to see that fucking pot again. It's fucking stupid. You can't dress up brokenness with gold and pretend it's attractive. You can't put lipstick on a hog and take it to dinner. You can't dance in the rain when your whole life is a hurricane. There's no light at the end of the tunnel when you're boring into the center of the earth. You can't be beautiful when at your core, you're an ugly slimy creepy wanker that billows through the dungeons like a bat in a bog." Pt was clearly dysregulated, and garrulous. 

SW reflected that SW will be glad to discuss the pottery, which seems to be evoking a lot of feelings for patient. In response pt stated, "If I see it again, it will be broken. That's a warning, not a threat. I beg you to hear me. The rage has a mind of its own. I'm not able to contain it fully. Don't test it." 

SW identified that pt has a choice in terms of his actions, but validated that pt feels unable to control those actions when it comes to objects of rage. SW affirmed that this will be a topic for future sessions. 

  
"What future sessions?" pt raged, and laughed bitterly. "Fuck you, Rosenberg. You think you can just tell me how to live my life? You think you can dangle _hope_ in front of me like candy in a baby's face, and make me dance? Fuck that, fuck you, and fuck Dr. Crane, the pompous twat." 

SW validated that pt must have felt condescended to at last session. Pt agreed, "Yeah, I felt fucking condescended to. I'm not some gullible eleven year old. Even at eleven I was too smart for this shite. My mother was right. I'm too smart by half." 

SW identified that SW will consult with BCH clinical staff and Dr. Crane may also consult re: pt's care. Pt stated, "Whatever, you do what you want to do, Rosenberg. I don't give a shite," and then hung up. 

SW will provide consultation and f/u accordingly. 


	23. 11.4.1998 '

Patient Information: Severus S 

Encounter Information: 11/4/1998 11:00am 

Clinician: Leticia Rosenberg LICSW

Session Duration: 60 minutes

Type of Session: Individual psychotherapy

PHQ9: not completed GAD7: not completed

**Follow Up from Previous Session:**

Pt discharged from BCH emergency room on 11/2/1998 after 24hr hold, and attended work on 11/3/1998. Pt attending session today (first available after pt's discharge) in the middle of his workday. He seemed pale and withdrawn, and avoided eye contact even more markedly than usual. 

Social worker extended an olive branch as patient sat down silently and refused to speak for the better part of two minutes. Social worker stated to patient, “I know it was really hard to do the right thing and follow the plan. it would’ve been easier to follow through with the impulse to kill yourself. It was brave to keep fighting despite what your instincts told you to do.“

patient looked aggrieved and snarled at clinician, “I am not the least bit brave. When push comes to shove, I can’t take the final Plunge into self-destruction. It’s too hard to let go and fall into the abyss, that’s what it is. For some insane reason, I cannot bring myself to do the one final act that would atone for my sins against humanity. Don’t speak of bravery and me in the same sentence ever again.”

**Focus of Today’s Session (what we talked about):**

Social worker and patient discussed the value of bravery and courage. SW mentioned the parable of David versus Goliath and this sounded like it was unfamiliar to pt. Pt endorsed knowledge of a similar story about a fairy versus a giant, which he recounted in very minimal detail. Sw attempted to get pt more invested in the telling of the story, but pt. Seemed reluctant to engage in storytelling.

"I do not care for fiction," patient stated, a stern and disapproving look on his face. SW provided education about Bruno Bettelheim and the role that stories can play in informing us of our unconscious fears, desires, passions, and values. Pt seemed skeptical and observed, "why can't I just tell you all that in plain English?" which sw found to be a fascinating response. / /note: mention this to Dr. Crane w/relation to pt's possible autistic condition. >

SW and pt talked about pt's experiences with bravery as a value, which seems to be a fraught history indeed. "I always have said that brains are superior to brawn," patient observed, a frown on his face. "1 have had very few positive experiences with those who profess to value bravery and courage.. So much of my life has been stained with blood under the guises of valor. I do not see the value in such atrocities. Courage so often is a word meant to praise the pig-headed and moronic and I loathe ever being associated with the idea. Call me cunning, call me bookish, call me a desperate love-lorn ninny, but brave and I do not mix." ****

SW and patient discussed pt's history with bravery in others, as he seems so impassioned on the topic. "It was James Potter's mantra, and that of his friends, " Severus stated, "and Al's as well. And his golden disciple, Harry. All of these.. . _men_ who tormented me, in one way or another, saw it as a value to be honored above all others. And to think of it makes my blood boil and my stomach knot.'.

SW asked then if pt sees himself as a coward. A glimmer of rage entered his face, and it was a sudden moment where SW saw some of the vile energy that pt embodied on Sunday morning on the phone. "I will forgive you that, Rosenberg, as I know you do not mean to insult me. But it simply bears out that I have been working to undo my innate cowardice since my earliest days at school.

"My mother taught me to adapt to bad situations - not to run, not to hide, just to accept, and ignore, and avoid, and ultimately to survive. My mother was not unkind to me as a child, but neither was she gentle. She did not shield me from the harshness and cruelty of the world. I know she loved me, but it was in a harsh way. A brittle way. The only way she could, mind, when she had learned the hard way that dreams are for the insipid and naïve, and that survival could only be assured through wit and patience.

"She said once that she learned her ways from the spider, crafty and brainy and resilient. I spent many hours of my childhood killing the flies that were attracted to my father's putrefying ale bottles, just watching and waiting and dexterously destroying. It was a way to entertain myself when my parents were going at it hammer and tongs."

SW asked if pt. Identified much with mother. Pt gave a grim half smile. "I just would hope 1'd be stronger if my partner regularly endangered my bodily self, much less that of my child. I would like to think I would if another's welfare was on the line. But as for my own welfare - if I loved someone as much and as hopelessly as my mother loved my father, I think it is more hubris to imagine that I would do much better. "  
  


SW contrasted pt's sense of bravery / "adaptivity" with that of pt's mother. Pt acknowledged, " I would be lying if I said I did not resent her choices. part of adapting is learning from the experiences of others. I would hope I successfully internalized the lessons of her life. "

SW endorsed being glad that pt. survived Halloween. Pt seemed to hold a move grim perspective. "This is just one more thing that hasn't killed me. If I were sensible, I would celebrate. As the cards fall, however, I remain dismayed and disappointed. "

Sw reflected that pt seems to have at least a tiny amount of hope. Pt denied this. SW recollected pt's words on the phone about now pt did not want pt's death on my (writer's) conscience. Pt seemed taken aback by this. SW also pointed out that pt seemed to have the same thought process when pt was planning to slit wrists in the shower, pertaining to the female shelter worker.

SW synthesized these observations to hypothesize that pt actually does have hope- but he displaces it and transmutes it into a more acceptable emotion of wanting to protect others.

Perhaps it was too early to broach this. Pt. did not respond but instead stomped out of the room without saying a word and left the clinic for the day.

After pt left, SW realized that SW had forgotten to remove the kitsugi pottery from its place on the shelf in advance of pt's appointment. Oddly, the pottery was shattered, whereas it had been intact before the appointment. SW remains puzzled by this as SW had remained in the room the whole time pt was present. A strange coincidence, perhaps... 

**Most Helpful Take-Away:** n/a

Treatment Goal(s) Addressed This Session: decreasing incidence and severity of anxiety symptoms, decreasing incidence and severity of depression symptoms, dec to haveat least reasing incidence and severity of suicidal ideation, decreasing incidence and severity of emotional dysregulation and distress symptoms, increasing independence and ability to self-actualize patient's goals, increasing patient self-esteem and sense of self-worth, increasing patient engagement in pleasurable activities (behavioral activation), increasing patient awareness of emotions and feelings, continuing patient engagement in treatment with mental health, evaluating patient medication management and stability, increasing patient coping skills and ability to tolerate distressing circumstances.

Objectives (steps to get to goals): attending regularly scheduled therapy appointment 

Methods Used: Motivational Interviewing, Interpersonal

Next Session: 11/9/1998

**Author's Note:**

> Fanfiction Writers and (non)Celebrities: What Do They Know? Do They Know Things?? Let's Find Out!  
> [Tumblr](https://lady-heliotrope-writes.tumblr.com/)  
> [Ko-Fi](https://ko-fi.com/ladyheliotrope)
> 
> guess what you know the SINGLE most important thing that keeps me writing? comments / reviews. every comment I get, I re-read the chapter you commented on and re-examine whatever you mentioned liking in a new light. it stirs the imagination like no other source of inspiration. if I'm just writing and sending out the story into the ether, chances are I'll lose interest and not finish. if I'm getting meaningful engagement from readers, that is the single most valuable thing that gets me motivated to write. 
> 
> life is hard right now. I'm so glad you're reading fanfiction as a way to self-care and cope.


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